Basic Information
| Provider Information | |||||||||
| NPI: | 1457340051 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAYSVILLE MANOR LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MAYSVILLE EXTENDED CARE FACILITY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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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: | 620 PARKER RD | ||||||||
| Address2: | |||||||||
| City: | MAYSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410569620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065644085 | ||||||||
| FaxNumber: | 6065648835 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2005 | ||||||||
| LastUpdateDate: | 05/05/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MORROW | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP OF ADMINISTRATIVE SUPPORT | ||||||||
| AuthorizedOfficialTelephone: | 8596230898 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 100333 | KY | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 12501292 | 05 | KY | MEDICAID | 90160763 | 05 | KY | MEDICAID |