Basic Information
| Provider Information | |||||||||
| NPI: | 1457340903 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARTIN MANOR LLC | ||||||||
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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: | 197 TURKEY CREEK ROAD | ||||||||
| Address2: | |||||||||
| City: | INEZ | ||||||||
| State: | KY | ||||||||
| PostalCode: | 41224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6062980091 | ||||||||
| FaxNumber: | 6062983084 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2005 | ||||||||
| LastUpdateDate: | 03/21/2013 | ||||||||
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| AuthorizedOfficialLastName: | MORROW | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OF ADMINISTRATIVE SUPPORT | ||||||||
| AuthorizedOfficialTelephone: | 8596230898 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 100661 | KY | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 12504197 | 05 | KY | MEDICAID | 7100231800 | 05 | KY | MEDICAID | 90160763 | 05 | KY | MEDICAID |