Healthcare Provider Details

I. General information

NPI: 1285103937
Provider Name (Legal Business Name): A NEWCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2018
Last Update Date: 02/12/2025
Certification Date: 02/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1939 GOLDSMITH LN STE 100
LOUISVILLE KY
40218-3090
US

IV. Provider business mailing address

9462 BROWNSBORO RD # 357
LOUISVILLE KY
40241-1118
US

V. Phone/Fax

Practice location:
  • Phone: 502-873-7517
  • Fax: 502-365-2876
Mailing address:
  • Phone: 502-873-7517
  • Fax: 502-365-2876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. BRUCE MELVIN COHEN
Title or Position: MEMBER
Credential:
Phone: 502-551-2460