Basic Information
| Provider Information | |||||||||
| NPI: | 1154354595 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIFELINE HEALTH CARE OF KENTUCKY #3, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 CLIFTY ST | ||||||||
| Address2: | |||||||||
| City: | SOMERSET | ||||||||
| State: | KY | ||||||||
| PostalCode: | 425031733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6066794100 | ||||||||
| FaxNumber: | 6066787306 | ||||||||
| Practice Location | |||||||||
| Address1: | 60 SHELTON LN | ||||||||
| Address2: | |||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 422767203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707262408 | ||||||||
| FaxNumber: | 2707267213 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WILSON | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | T. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6066794100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | X | Agencies | Home Health | 261QR0400X | X | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation | 261QR1300X | X | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 45342565 | 05 | KY | MEDICAID | 34004713 | 05 | KY | MEDICAID | 42007112 | 05 | KY | MEDICAID |