Provider Demographics
NPI:1902839434
Name:HQM OF LEXINGTON, LLC
Entity Type:Organization
Organization Name:HQM OF LEXINGTON, LLC
Other - Org Name:MAYFAIR MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:WALCZAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-627-0664
Mailing Address - Street 1:3300 TATES CREEK RD
Mailing Address - Street 2:FAYETTE COUNTY
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40502-3408
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3300 TATES CREEK RD
Practice Address - Street 2:FAYETTE COUNTY
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40502-3408
Practice Address - Country:US
Practice Address - Phone:859-266-2126
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY12504353Medicaid
KY18-5069Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER