Basic Information
| Provider Information | |||||||||
| NPI: | 1134267669 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ACSR, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ACTIVE DAY OF PADUCAH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 6 NESHAMINY INTERPLEX DR STE 401 | ||||||||
| Address2: | |||||||||
| City: | TREVOSE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190536942 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156426600 | ||||||||
| FaxNumber: | 2158275950 | ||||||||
| Practice Location | |||||||||
| Address1: | 2005 BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420017107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704427604 | ||||||||
| FaxNumber: | 2704422082 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2007 | ||||||||
| LastUpdateDate: | 03/02/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOCKENBURY | ||||||||
| AuthorizedOfficialFirstName: | DEBORA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CONTRACTS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2156426600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ACTIVE DAY, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0400X | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation | 261QA0600X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Day Care |
ID Information
| ID | Type | State | Issuer | Description | 4300069400 | 05 | KY | MEDICAID |