Basic Information
Provider Information | |||||||||
NPI: | 1558455824 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KENTON HEALTHCARE CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7400 NEW LAGRANGE RD | ||||||||
Address2: | #100 | ||||||||
City: | LOUISVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 402224870 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5024298062 | ||||||||
FaxNumber: | 5024295980 | ||||||||
Practice Location | |||||||||
Address1: | 353 WALLER AVE | ||||||||
Address2: |   | ||||||||
City: | LEXINGTON | ||||||||
State: | KY | ||||||||
PostalCode: | 405042901 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8592523558 | ||||||||
FaxNumber: | 8592330192 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/03/2006 | ||||||||
LastUpdateDate: | 02/20/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TSCHUDI | ||||||||
AuthorizedOfficialFirstName: | ALLEN | ||||||||
AuthorizedOfficialMiddleName: | CRAIG | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
AuthorizedOfficialTelephone: | 5024298062 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BN1400X | 100113 | KY | N |   | Suppliers | Durable Medical Equipment & Medical Supplies | Nursing Facility Supplies | 332BP3500X | 100113 | KY | N |   | Suppliers | Durable Medical Equipment & Medical Supplies | Parenteral & Enteral Nutrition | 314000000X | 100113 | KY | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 12504569 | 05 | KY |   | MEDICAID |