Basic Information
| Provider Information | |||||||||
| NPI: | 1548402720 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHRISTIAN CARE CENTER OF KUTTAWA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2020 NORTHPARK | ||||||||
| Address2: | SUITE 2D | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376043127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239755455 | ||||||||
| FaxNumber: | 4239755405 | ||||||||
| Practice Location | |||||||||
| Address1: | 1253 LAKE BARKLEY DRIVE | ||||||||
| Address2: | |||||||||
| City: | KUTTAWA | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420556124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2703882291 | ||||||||
| FaxNumber: | 2703880948 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2009 | ||||||||
| LastUpdateDate: | 10/14/2010 | ||||||||
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| AuthorizedOfficialLastName: | CAWOOD-GRAY | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | RISK CONSULTANT | ||||||||
| AuthorizedOfficialTelephone: | 4239755455 | ||||||||
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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 | 313M00000X | 100300 | KY | N | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 314000000X | 100300 | KY | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 7100070570 | 05 | KY | MEDICAID |