Healthcare Provider Details

I. General information

NPI: 1598056210
Provider Name (Legal Business Name): COMMONWEALTH OF KENTUCKY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2011
Last Update Date: 10/30/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10510 LAGRANGE ROAD
LOUISVILLE KY
40223
US

IV. Provider business mailing address

10510 LAGRANGE ROAD
LOUISVILLE KY
40223
US

V. Phone/Fax

Practice location:
  • Phone: 502-253-7000
  • Fax: 503-253-7090
Mailing address:
  • Phone: 502-253-7000
  • Fax: 503-253-7090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateKY

VIII. Authorized Official

Name: JENNIFER MOORE
Title or Position: ASSISTANT DIRECTOR
Credential:
Phone: 502-782-6117