Healthcare Provider Details

I. General information

NPI: 1942203955
Provider Name (Legal Business Name): LIFESCAN OF LOUISVILLE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 01/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4046 DUTCHMANS LN
LOUISVILLE KY
40207-4712
US

IV. Provider business mailing address

4046 DUTCHMANS LN
LOUISVILLE KY
40207-4712
US

V. Phone/Fax

Practice location:
  • Phone: 502-893-7145
  • Fax: 502-893-7147
Mailing address:
  • Phone: 502-893-7145
  • Fax: 502-893-7147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. MICHELLE DOUGLAS
Title or Position: CONTRACT MANAGER
Credential:
Phone: 502-403-1401