Basic Information
Provider Information | |||||||||
NPI: | 1780617126 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LIFELINE HEALTH CARE OF CENTRAL KENTUCKY, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 600 CLIFTY ST | ||||||||
Address2: |   | ||||||||
City: | SOMERSET | ||||||||
State: | KY | ||||||||
PostalCode: | 425031733 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6066794100 | ||||||||
FaxNumber: | 6066787306 | ||||||||
Practice Location | |||||||||
Address1: | 155 W TIVERTON WAY | ||||||||
Address2: | SUITE 3 | ||||||||
City: | LEXINGTON | ||||||||
State: | KY | ||||||||
PostalCode: | 405034418 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8592729787 | ||||||||
FaxNumber: | 8592724698 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/09/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WILSON | ||||||||
AuthorizedOfficialFirstName: | JAMES | ||||||||
AuthorizedOfficialMiddleName: | T. | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 6066794100 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X |   |   | X |   | Agencies | Home Health |   | 261QR0400X |   |   | X |   | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation | 261QR1300X |   |   | X |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
ID | Type | State | Issuer | Description | 42000026 | 05 | KY |   | MEDICAID | 45000536 | 05 | KY |   | MEDICAID | 34000067 | 05 | KY |   | MEDICAID |