=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215327994
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMUNITY CARE OF KENTUCKY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2015
-----------------------------------------------------
Last Update Date | 02/04/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3438 TAYLOR BLVD
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40215-2648
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-366-4442
-----------------------------------------------------
Fax | 502-366-4446
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3438 TAYLOR BLVD
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40215-2648
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-366-4442
-----------------------------------------------------
Fax | 502-366-4446
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | TODD CRUSE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 629-999-5006
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------