Provider Demographics
NPI:1669542825
Name:BREATITT COUNTY GERIATRIC CORPORATION
Entity type:Organization
Organization Name:BREATITT COUNTY GERIATRIC CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:
Authorized Official - Last Name:LITTERAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-666-2456
Mailing Address - Street 1:420 JETT DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:KY
Mailing Address - Zip Code:41339-9621
Mailing Address - Country:US
Mailing Address - Phone:606-666-2456
Mailing Address - Fax:606-666-9376
Practice Address - Street 1:420 JETT DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:KY
Practice Address - Zip Code:41339-9621
Practice Address - Country:US
Practice Address - Phone:606-666-2456
Practice Address - Fax:606-666-9376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY100040314000000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000054703OtherBLUE CROSS BLUE SHIELD
KY543892824OtherBLACK LUNG
KY9013013900Medicaid
KY12501524Medicaid
KY185112Medicare ID - Type Unspecified
KY12501524Medicaid