Basic Information
| Provider Information | |||||||||
| NPI: | 1861612681 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MID-SOUTH NURSING HOMES, INC | ||||||||
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| OtherOrganizationName: | PINECREST MANOR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 602 COURTLAND ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328041360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079753000 | ||||||||
| FaxNumber: | 4079753090 | ||||||||
| Practice Location | |||||||||
| Address1: | 950 HIGHPOINT DR | ||||||||
| Address2: | |||||||||
| City: | HOPKINSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 422402570 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708851151 | ||||||||
| FaxNumber: | 2708857461 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WEHTJE | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | VP CFO | ||||||||
| AuthorizedOfficialTelephone: | 4079753010 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 100070 | KY | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 90003997 | 05 | KY | MEDICAID | 12500153 | 05 | KY | MEDICAID |