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General NPI Number Information
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NPI Number | 1578871679
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Entity Type | Organization
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Legal Business Name | COMMONWEALTH OF KENTUCKY
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Dates
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Enumeration Date | 09/23/2010
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Last Update Date | 10/30/2024
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Provider Practice Location Address
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Address Line | 10510 LAGRANGE ROAD
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City | LOUISVILLE
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State | KY
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Zip | 40223
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Country | US
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Telephone | 502-253-7000
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Fax | 503-253-7044
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Provider Business Mailing Address
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Address Line | 10510 LAGRANGE ROAD
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City | LOUISVILLE
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State | KY
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Zip | 40223
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Country | US
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Telephone | 502-253-7000
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Fax | 503-253-7044
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Authorized Official
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Title or Position | ASSISTANT DIRECTOR
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Name | JENNIFER MOORE
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Credential |
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Telephone | 502-782-6117
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 283Q00000X
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Taxonomy Name | Psychiatric Hospital
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 283Q00000X
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Taxonomy Name | Psychiatric Hospital
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License Number |
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License Number State | KY
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