Provider Demographics
NPI:1205267671
Name:ASSUREDLINK CASE MANAGEMENT AGENCY
Entity type:Organization
Organization Name:ASSUREDLINK CASE MANAGEMENT AGENCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DEMETRIUS
Authorized Official - Middle Name:DEPP
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:ED
Authorized Official - Phone:270-303-4669
Mailing Address - Street 1:1990 LOUISVILLE RD
Mailing Address - Street 2:101
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-1202
Mailing Address - Country:US
Mailing Address - Phone:270-599-0212
Mailing Address - Fax:
Practice Address - Street 1:1990 LOUISVILLE RD
Practice Address - Street 2:101
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-1202
Practice Address - Country:US
Practice Address - Phone:270-599-0212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-10
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY171431101YP2500X
KY7100347620251B00000X
KYK12245600347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes347C00000XTransportation ServicesPrivate Vehicle
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100224880Medicaid
KY7100438780Medicaid
KY7100347620Medicaid