Basic Information
| Provider Information | |||||||||
| NPI: | 1235137530 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WELLINGTON PARC HEALTH SYSTEMS, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WELLINGTON PARC OF BOWLING GREEN | ||||||||
| 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: | 1381 CAMPBELL LN | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421041049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708430587 | ||||||||
| FaxNumber: | 2708430874 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2005 | ||||||||
| 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 | 100647 | KY | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 12503348 | 05 | KY | MEDICAID |