Healthcare Provider Details

I. General information

NPI: 1205554474
Provider Name (Legal Business Name): AMELIA PANTALOS L.AC., LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2022
Last Update Date: 08/15/2022
Certification Date: 08/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 WALLACE AVE
LOUISVILLE KY
40207-3007
US

IV. Provider business mailing address

311 WALLACE AVE
LOUISVILLE KY
40207-3007
US

V. Phone/Fax

Practice location:
  • Phone: 502-290-8788
  • Fax:
Mailing address:
  • Phone: 502-718-6881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number172924
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC119
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: