Healthcare Provider Details

I. General information

NPI: 1720090525
Provider Name (Legal Business Name): CPO PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 05/27/2022
Certification Date: 05/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4402 CHURCHMAN AVE SUITE 404
LOUISVILLE KY
40215-1190
US

IV. Provider business mailing address

PO BOX 30563
BELFAST ME
04915-2057
US

V. Phone/Fax

Practice location:
  • Phone: 502-363-4156
  • Fax:
Mailing address:
  • Phone: 888-488-8289
  • Fax: 502-919-9780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number31716
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5222
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number31716
License Number StateKY

VIII. Authorized Official

Name: LAWRENCE H PETERS
Title or Position: MD
Credential: MD
Phone: 502-366-0970