Healthcare Provider Details

I. General information

NPI: 1104603836
Provider Name (Legal Business Name): MBOKA COMMUNITY SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2023
Last Update Date: 09/14/2023
Certification Date: 09/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3514 RAMONA AVE
LOUISVILLE KY
40220-2411
US

IV. Provider business mailing address

3514 RAMONA AVE
LOUISVILLE KY
40220-2411
US

V. Phone/Fax

Practice location:
  • Phone: 502-671-9908
  • Fax:
Mailing address:
  • Phone: 502-671-9908
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: ELIZABETH BASS
Title or Position: CO-OWNER
Credential: RN
Phone: 502-671-9908