=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871492645
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SKYBOUND PROVIDER GROUP, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2026
-----------------------------------------------------
Last Update Date | 11/05/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 312 S 4TH ST
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40202-3002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-322-3658
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 927 E MAIN ST STE 66505
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40206-1963
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. YAVAR MOGHIMI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 571-228-5031
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------