Provider Demographics
NPI:1902839020
Name:PRESBYTERIAN HOMES AND SERVICES OF KENTUCKY, INC.
Entity Type:Organization
Organization Name:PRESBYTERIAN HOMES AND SERVICES OF KENTUCKY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HATTIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-259-9101
Mailing Address - Street 1:PO BOX 18067
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40261-0067
Mailing Address - Country:US
Mailing Address - Phone:270-769-0058
Mailing Address - Fax:270-737-3096
Practice Address - Street 1:106 DIECKS DRIVE
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701
Practice Address - Country:US
Practice Address - Phone:270-769-0058
Practice Address - Fax:270-737-3096
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRESBYTERIAN HOMES AND SERVICES OF KENTUCKY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-09
Last Update Date:2017-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY002058225100000X
KY004490225100000X
KYR2591225X00000X
KYR2338225X00000X
KY2470235Z00000X
KY101012261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY186517Medicare ID - Type UnspecifiedMEDICARE NUMBER