Provider Demographics
NPI:1922643287
Name:KENTUCKY CUSTOM CARE PROFESSIONALS
Entity Type:Organization
Organization Name:KENTUCKY CUSTOM CARE PROFESSIONALS
Other - Org Name:KENTUCKY CUSTOM CARE PROFESSIONALS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:FENWICK
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:502-331-1085
Mailing Address - Street 1:3200 PATTON RD
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:KY
Mailing Address - Zip Code:40107-8700
Mailing Address - Country:US
Mailing Address - Phone:502-331-1085
Mailing Address - Fax:
Practice Address - Street 1:3200 PATTON RD
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:KY
Practice Address - Zip Code:40107-8700
Practice Address - Country:US
Practice Address - Phone:502-331-1085
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-11
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care FacilityGroup - Multi-Specialty
No163WH0200XNursing Service ProvidersRegistered NurseHome HealthGroup - Multi-Specialty
No372600000XNursing Service Related ProvidersAdult CompanionGroup - Multi-Specialty