Provider Demographics
NPI:1649484015
Name:VILLAGE OF LEBANON II, LLC
Entity type:Organization
Organization Name:VILLAGE OF LEBANON II, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:B
Authorized Official - Last Name:GEORGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-751-6823
Mailing Address - Street 1:105 VILLAGE WAY
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:KY
Mailing Address - Zip Code:40033-1845
Mailing Address - Country:US
Mailing Address - Phone:270-692-9000
Mailing Address - Fax:270-699-3691
Practice Address - Street 1:105 VILLAGE WAY
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:KY
Practice Address - Zip Code:40033-1845
Practice Address - Country:US
Practice Address - Phone:270-692-9000
Practice Address - Fax:270-699-3691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY100646313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100236520Medicaid
KY185437Medicare Oscar/Certification