Basic Information
| Provider Information | |||||||||
| NPI: | 1649484015 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VILLAGE OF LEBANON II, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 VILLAGE WAY | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 400331845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706929000 | ||||||||
| FaxNumber: | 2706993691 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 VILLAGE WAY | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 400331845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706929000 | ||||||||
| FaxNumber: | 2706993691 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2007 | ||||||||
| LastUpdateDate: | 04/27/2018 | ||||||||
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| AuthorizedOfficialLastName: | GEORGE | ||||||||
| AuthorizedOfficialFirstName: | TIM | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5027516823 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 100646 | KY | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
ID Information
| ID | Type | State | Issuer | Description | 7100236520 | 05 | KY | MEDICAID |