MEDICARE: AGAPE COMMUNITY LIVING LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	251S00000X	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164787958
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AGAPE COMMUNITY LIVING LLC

Provider Business Mailing Address
First Line	:	4200 WALLINGFORD LN
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40218-2720
Country	:	US
Telephone Number	:	502-749-3257
Fax Number	:	502-742-3141

Provider Business Practice Location Address
First Line	:	4200 WALLINGFORD LN
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40218-2720
Country	:	US
Telephone Number	:	502-749-3257
Fax Number	:	502-742-3141

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MRS. CAROL VIBBERT
Credential	:	RN, BSN
Telephone Number	:	502-749-3257

Provider Enumeration Date	:	07/09/2012
Last Update Date	:	07/09/2012

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