Basic Information
| Provider Information | |||||||||
| NPI: | 1437148046 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DJ LETCHER MANOR LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LETCHER MANOR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 PROVIDER CT | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | RICHMOND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404758488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8596230898 | ||||||||
| FaxNumber: | 8596230843 | ||||||||
| Practice Location | |||||||||
| Address1: | 73 PIEDMONT DR | ||||||||
| Address2: | |||||||||
| City: | WHITESBURG | ||||||||
| State: | KY | ||||||||
| PostalCode: | 418587668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6066331434 | ||||||||
| FaxNumber: | 6066333450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2005 | ||||||||
| LastUpdateDate: | 05/06/2008 | ||||||||
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| AuthorizedOfficialLastName: | MORROW | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP OF ADMINISTRATIVE SUPPORT | ||||||||
| AuthorizedOfficialTelephone: | 8596230898 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 100604 | KY | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 90160763 | 05 | KY | MEDICAID | 12504189 | 05 | KY | MEDICAID |