Provider Demographics
NPI:1396962551
Name:COMMONWEALTH OF KENTUCKY
Entity type:Organization
Organization Name:COMMONWEALTH OF KENTUCKY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:CAROLYN
Authorized Official - Last Name:BRANHAM
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:606-435-6196
Mailing Address - Street 1:200 VETERANS DR
Mailing Address - Street 2:
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41701-9484
Mailing Address - Country:US
Mailing Address - Phone:606-345-6196
Mailing Address - Fax:606-435-6201
Practice Address - Street 1:200 VETERANS DR
Practice Address - Street 2:
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701-9484
Practice Address - Country:US
Practice Address - Phone:606-345-6196
Practice Address - Fax:606-435-6201
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMONWEALTH OF KENTUCKY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-19
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY100990313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY100990OtherLICENSE