| NPI | 1811517774 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | ANGIE MATTINGLY Manager Provider Enrollment 502-381-3579 |
| Organization Subpart ? | No |
| Primary Taxonomy | 315P00000X Intermediate Care Facility, Mentally Retarded |
| Enumeration Date | 2020-04-21 |
| Last Update Date | 2020-04-21 |