Basic Information
| Provider Information | |||||||||
| NPI: | 1316136534 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. ELIZABETH HOME CARE SERVICES, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ST. ELIZABETH HOME CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6281 TRI RIDGE BLVD STE 300 | ||||||||
| Address2: | |||||||||
| City: | LOVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 451408345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135760262 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8100 BURLINGTON PIKE | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410421261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592831500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2007 | ||||||||
| LastUpdateDate: | 07/20/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HAWKINS | ||||||||
| AuthorizedOfficialFirstName: | JACK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP, FINANCE & CFO | ||||||||
| AuthorizedOfficialTelephone: | 5135768478 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | 150016 | KY | N | Agencies | Case Management | 251J00000X | 150016 | KY | N | Agencies | Nursing Care | 251K00000X | N | Agencies | Public Health or Welfare | 252Y00000X | 150016 | KY | N | Agencies | Early Intervention Provider Agency | 251E00000X | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 7100397900 | 01 | KY | MEDICAID PRIVATE DUTY | OTHER | 7100060090 | 05 | KY | MEDICAID | 7100071690 | 01 | KY | MEDICAID WAIVER | OTHER | 7100073700 | 01 | KY | HCBW | OTHER | 7100076670 | 01 | KY | EPSDT | OTHER |