Healthcare Provider Details

I. General information

NPI: 1083785125
Provider Name (Legal Business Name): COMMONWEALTH OF KENTUCKY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2006
Last Update Date: 08/07/2024
Certification Date: 08/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401-4505 LOUISE UNDERWOOD WAY
LOUISVILLE KY
40216
US

IV. Provider business mailing address

4401-4505 LOUISE UNDERWOOD WAY
LOUISVILLE KY
40216
US

V. Phone/Fax

Practice location:
  • Phone: 502-363-6421
  • Fax: 502-363-2215
Mailing address:
  • Phone: 502-363-8421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number
License Number State

VIII. Authorized Official

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