Provider Demographics
NPI:1881799807
Name:KENTUCKY EASTER SEAL SOCIETY INC
Entity type:Organization
Organization Name:KENTUCKY EASTER SEAL SOCIETY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT/CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARTY
Authorized Official - Middle Name:A
Authorized Official - Last Name:LAUTNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-254-5701
Mailing Address - Street 1:2050 VERSAILLES RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-1405
Mailing Address - Country:US
Mailing Address - Phone:859-254-5701
Mailing Address - Fax:859-233-1615
Practice Address - Street 1:2050 VERSAILLES RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-1405
Practice Address - Country:US
Practice Address - Phone:859-254-5701
Practice Address - Fax:859-233-1615
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KENTUCKY EASTER SEAL SOCIETY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-14
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY100100261Q00000X, 283X00000X
KYP05154333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283X00000XHospitalsRehabilitation Hospital
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2638739Medicaid
KY01021237Medicaid
1062621OtherPASSPORT
KY253OtherFIRST STEPS
000000054501OtherANTHEM
000000054501OtherANTHEM
KY183026Medicare ID - Type Unspecified