Healthcare Provider Details

I. General information

NPI: 1902351570
Provider Name (Legal Business Name): LOUISSAINT LOUIS XVI CSA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2016
Last Update Date: 08/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 NEWBURG RD
LOUISVILLE KY
40205-1803
US

IV. Provider business mailing address

1607 HERR LN
LOUISVILLE KY
40222-6543
US

V. Phone/Fax

Practice location:
  • Phone: 502-451-3330
  • Fax:
Mailing address:
  • Phone: 859-797-0675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number4650
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: