Provider Demographics
NPI:1053344457
Name:BOURBON HEIGHTS, INC.
Entity type:Organization
Organization Name:BOURBON HEIGHTS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CHARLOTTE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-987-5750
Mailing Address - Street 1:2000 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:KY
Mailing Address - Zip Code:40361-1149
Mailing Address - Country:US
Mailing Address - Phone:859-987-5750
Mailing Address - Fax:859-987-6460
Practice Address - Street 1:2000 MAIN ST
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:KY
Practice Address - Zip Code:40361-1149
Practice Address - Country:US
Practice Address - Phone:859-987-5750
Practice Address - Fax:859-987-6460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY100024313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY12501664Medicaid
19401888OtherSUMMIT WORKER'S COMP
000000054629OtherANTHEM BLUE CROSS BLUE SH
KY12501664Medicaid
1006360001Medicare NSC
KY185283Medicare ID - Type Unspecified