Basic Information
| Provider Information | |||||||||
| NPI: | 1871594747 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PADUCAH HEALTH SERVICES, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PADUCAH CENTRE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 725 HARVARD DR | ||||||||
| Address2: | |||||||||
| City: | OWENSBORO | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423016185 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2709269355 | ||||||||
| FaxNumber: | 2706846283 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 N 3RD ST | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420010749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704449661 | ||||||||
| FaxNumber: | 2704439407 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SKAGGS | ||||||||
| AuthorizedOfficialFirstName: | TERRY | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2709269355 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 100309 | KY | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 5419010001 | 01 | KY | PART B SUPPLIER | OTHER | 12504627 | 05 | KY | MEDICAID |