Healthcare Provider Details

I. General information

NPI: 1750568812
Provider Name (Legal Business Name): LOUISVILLE ASSISTED LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2008
Last Update Date: 07/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6830 OVERLOOK DR
LOUISVILLE KY
40241-6579
US

IV. Provider business mailing address

6830 OVERLOOK DR
LOUISVILLE KY
40241-6579
US

V. Phone/Fax

Practice location:
  • Phone: 502-423-7177
  • Fax: 502-423-7181
Mailing address:
  • Phone: 502-423-7177
  • Fax: 502-423-7181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number100932
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number100932
License Number StateKY

VIII. Authorized Official

Name: MS. ANGELIQUE WELLS
Title or Position: ADMINSTRATOR
Credential:
Phone: 502-423-7177