Provider Demographics
NPI:1881683480
Name:MIDDLESBORO MANOR LLC
Entity Type:Organization
Organization Name:MIDDLESBORO MANOR LLC
Other - Org Name:MIDDLESBORO HEALTH CARE FACILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF ADMINISTRATIVE SUPPORT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MORROW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-623-0898
Mailing Address - Street 1:300 PROVIDER CT
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-8488
Mailing Address - Country:US
Mailing Address - Phone:859-623-0898
Mailing Address - Fax:859-623-0843
Practice Address - Street 1:235 NEW WILSON LN
Practice Address - Street 2:
Practice Address - City:MIDDLESBORO
Practice Address - State:KY
Practice Address - Zip Code:40965-2705
Practice Address - Country:US
Practice Address - Phone:606-248-0925
Practice Address - Fax:606-242-2544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-17
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY100639314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY12504205Medicaid
KY7100244560Medicaid
KY90160763Medicaid
KY7100244560Medicaid
KY12504205Medicaid