Basic Information
| Provider Information | |||||||||
| NPI: | 1669612008 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LIVINGSTON HOSPITAL AND HEALTHCARE SERVICES, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GRAND LAKES CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 131 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420788043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2709887296 | ||||||||
| FaxNumber: | 2709883900 | ||||||||
| Practice Location | |||||||||
| Address1: | 1860 J.H. O'BRYAN AVE. | ||||||||
| Address2: | |||||||||
| City: | GRAND RIVERS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2703628246 | ||||||||
| FaxNumber: | 2703629757 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2009 | ||||||||
| LastUpdateDate: | 08/05/2011 | ||||||||
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| AuthorizedOfficialLastName: | EDWARDS | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR//CEO | ||||||||
| AuthorizedOfficialTelephone: | 2709887235 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | 900135 | KY | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.