Basic Information
| Provider Information | |||||||||
| NPI: | 1659394054 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KINDRED NURSING CENTERS EAST, L.L.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 680 S 4TH ST | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402022407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5925967301 | ||||||||
| FaxNumber: | 5025964134 | ||||||||
| Practice Location | |||||||||
| Address1: | 75 MCMILLEN DR | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430551808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403440357 | ||||||||
| FaxNumber: | 7403448621 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 10/19/2017 | ||||||||
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| AuthorizedOfficialLastName: | WEAVER | ||||||||
| AuthorizedOfficialFirstName: | MARILYN | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 5025967300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KINDRED HEALTHCARE, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 5482 | OH | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 522085570001 | 01 | OH | AETNA | OTHER | 000000157668 | 01 | OH | ANTHEM | OTHER | 01-03319 | 05 | OH | MEDICAID |