Provider Demographics
NPI:1982123212
Name:SPECTRE & QUEEN
Entity Type:Organization
Organization Name:SPECTRE & QUEEN
Other - Org Name:FIRSTLIGHT OF THE FOOTHILLS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHADOW
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:SKAGGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-393-0669
Mailing Address - Street 1:326 S COURT ST
Mailing Address - Street 2:
Mailing Address - City:GRAYSON
Mailing Address - State:KY
Mailing Address - Zip Code:41143-1269
Mailing Address - Country:US
Mailing Address - Phone:606-393-0669
Mailing Address - Fax:606-393-0675
Practice Address - Street 1:326 S COURT ST
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:KY
Practice Address - Zip Code:41143-1269
Practice Address - Country:US
Practice Address - Phone:606-393-0669
Practice Address - Fax:606-393-0675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY500280385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY500280OtherCOMMONWEALTH OF KENTUCKY CABINET FOR HEALTH AND FAMILY SERVICES