Provider Demographics
NPI:1922001148
Name:DOVER MANOR, INC.
Entity Type:Organization
Organization Name:DOVER MANOR, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT CONTROLLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:J
Authorized Official - Last Name:MCINTOSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-338-2401
Mailing Address - Street 1:PO BOX 529
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42345-0529
Mailing Address - Country:US
Mailing Address - Phone:270-338-2401
Mailing Address - Fax:270-338-2405
Practice Address - Street 1:112 DOVER DR
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-9741
Practice Address - Country:US
Practice Address - Phone:502-863-9529
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY100480314000000X
KY90003377332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000316058OtherANTHEM BLUE CROSS PART B
KY90003377Medicaid
KY000000271318OtherANTHEM BLUE CROSS
KY12501755Medicaid
KY000000316058OtherANTHEM BLUE CROSS PART B
KY90003377Medicaid