MEDICARE: BURUNDIAN COMMUNITY OF KENTUCKY, INC.

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	251S00000X	Community/Behavioral Health Agency	LPCCCA00225130	KY

General Provider Information

NPI Number	:	1245689264
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BURUNDIAN COMMUNITY OF KENTUCKY, INC.

Provider Business Mailing Address
First Line	:	1300 S 4TH ST STE 240
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40208-2314
Country	:	US
Telephone Number	:	502-650-3804
Fax Number	:

Provider Business Practice Location Address
First Line	:	1300 S 4TH ST STE 240
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40208-2314
Country	:	US
Telephone Number	:	502-650-3804
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	VICTOR EDDIE SR.
Credential	:
Telephone Number	:	502-650-3804

Provider Enumeration Date	:	06/09/2016
Last Update Date	:	06/09/2016

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