Healthcare Provider Details

I. General information

NPI: 1245253160
Provider Name (Legal Business Name): PARK DUVALLE COMMUNITY HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 11/02/2021
Certification Date: 11/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3015 WILSON AVE
LOUISVILLE KY
40211-1969
US

IV. Provider business mailing address

3015 WILSON AVE
LOUISVILLE KY
40211-1969
US

V. Phone/Fax

Practice location:
  • Phone: 502-774-4401
  • Fax: 502-772-4783
Mailing address:
  • Phone: 502-774-4401
  • Fax: 502-772-4783

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number700005
License Number StateKY

VIII. Authorized Official

Name: SWANNIE JETT
Title or Position: CEO
Credential:
Phone: 502-774-4401