Provider Demographics
NPI:1245657857
Name:COMMONWEALTH OF KENTUCKY
Entity type:Organization
Organization Name:COMMONWEALTH OF KENTUCKY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-782-6117
Mailing Address - Street 1:2441 US HIGHWAY 27
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42501
Mailing Address - Country:US
Mailing Address - Phone:606-677-4068
Mailing Address - Fax:606-677-4148
Practice Address - Street 1:2441 US HIGHWAY 27
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42501
Practice Address - Country:US
Practice Address - Phone:606-677-4068
Practice Address - Fax:606-677-4148
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMONWEALTH OF KENTUCKY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-03-20
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM1300X
KY261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100284200Medicaid
KY740294OtherCHFS LICENSE NUMBER