Healthcare Provider Details

I. General information

NPI: 1770896870
Provider Name (Legal Business Name): FRED HOUSE SPECIALIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2010
Last Update Date: 07/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9604 FIRWOOD CT
LOUISVILLE KY
40291-1027
US

IV. Provider business mailing address

9604 FIRWOOD CT
LOUISVILLE KY
40291-1027
US

V. Phone/Fax

Practice location:
  • Phone: 502-645-9231
  • Fax:
Mailing address:
  • Phone: 502-645-9231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number1083707
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: