Basic Information
| Provider Information | |||||||||
| NPI: | 1023299062 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KENTUCKY RIVER COMMUNITY CARE, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 115 ROCKWOOD LN | ||||||||
| Address2: | |||||||||
| City: | HAZARD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 417019415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064365761 | ||||||||
| FaxNumber: | 6064365797 | ||||||||
| Practice Location | |||||||||
| Address1: | 115 ROCKWOOD LN | ||||||||
| Address2: | |||||||||
| City: | HAZARD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 417019415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064365761 | ||||||||
| FaxNumber: | 6064365797 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2007 | ||||||||
| LastUpdateDate: | 04/10/2020 | ||||||||
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| AuthorizedOfficialLastName: | ADAMS | ||||||||
| AuthorizedOfficialFirstName: | MARCIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6066664351 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 28012011 | 05 | KY | MEDICAID |