Healthcare Provider Details

I. General information

NPI: 1801630512
Provider Name (Legal Business Name): 4418 MALCOLM AVENUE OPS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2024
Last Update Date: 06/19/2024
Certification Date: 06/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4418 MALCOLM AVE
LOUISVILLE KY
40215-1122
US

IV. Provider business mailing address

133 HOLIDAY CT STE 102
FRANKLIN TN
37067-1386
US

V. Phone/Fax

Practice location:
  • Phone: 502-713-7017
  • Fax: 833-792-1347
Mailing address:
  • Phone: 615-281-9050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: ALICIA NEAL
Title or Position: MANAGER, CRED & CONTRACTING
Credential:
Phone: 615-281-9050