Provider Demographics
NPI:1912995127
Name:PROFESSIONAL HOME HEALTH CARE AGENCY, INC.
Entity Type:Organization
Organization Name:PROFESSIONAL HOME HEALTH CARE AGENCY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOYCE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-877-1135
Mailing Address - Street 1:4934 S LAUREL RD
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40744-7985
Mailing Address - Country:US
Mailing Address - Phone:606-864-0724
Mailing Address - Fax:606-864-5256
Practice Address - Street 1:4934 S LAUREL RD
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40744-7985
Practice Address - Country:US
Practice Address - Phone:606-864-0724
Practice Address - Fax:606-864-5256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY42620021251B00000X
KY150090251E00000X
KY251J00000X, 291U00000X
KY90012964251X00000X
KY45343969252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251B00000XAgenciesCase Management
No251J00000XAgenciesNursing Care
No251X00000XAgenciesSupports Brokerage
No252Y00000XAgenciesEarly Intervention Provider Agency
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY45343969OtherEPSDT
KY42620021OtherHCBW
KY34620039Medicaid
KY90012964OtherKMA DME
KY187146Medicare ID - Type Unspecified
KY42620021OtherHCBW
KY5628860001Medicare NSC