Healthcare Provider Details

I. General information

NPI: 1326885013
Provider Name (Legal Business Name): 2022 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2024
Last Update Date: 05/30/2025
Certification Date: 05/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1229 ARCADE AVE
LOUISVILLE KY
40215-2203
US

IV. Provider business mailing address

4104 SMARTY JONES DR
LOUISVILLE KY
40214-6530
US

V. Phone/Fax

Practice location:
  • Phone: 502-384-0939
  • Fax: 502-384-6008
Mailing address:
  • Phone: 502-759-6281
  • Fax: 502-772-1533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name: XAVIER GILES
Title or Position: OWNER
Credential:
Phone: 502-384-0939