Membership Application

Home/Facility
Administrator / Executive Director
Phone
FAX
Address
City
State
Zip
E-mail
Web Site

 Specify number of licensed beds/units for each of the following:

Independent Living (Units) Nursing Facility (NF) (Beds)
Congregate Care (Units) Nursing Home (NH) (Beds)
Assisted Living Facility  (Units) Personal Care (PC) (Beds)
Intermediate Care (ICF) (Beds)
Skilled Nursing (SNF) (Beds)
 

2501 Nelson Miller Parkway
Louisville, KY 40223
502-992-4380
502-992-4390 - FAX
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