Provider Demographics
NPI:1881865863
Name:GAINESVILLE MANOR
Entity Type:Organization
Organization Name:GAINESVILLE MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:IDA
Authorized Official - Middle Name:
Authorized Official - Last Name:WOODARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-886-0258
Mailing Address - Street 1:550 MOORES DR
Mailing Address - Street 2:
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42240
Mailing Address - Country:US
Mailing Address - Phone:270-886-0258
Mailing Address - Fax:
Practice Address - Street 1:550 MOORES DR
Practice Address - Street 2:
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240
Practice Address - Country:US
Practice Address - Phone:270-886-0258
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-18
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY100066311Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility