MEDICARE: PAX HOUSE 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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1619450186
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAX HOUSE INC.

Provider Business Mailing Address
First Line	:	2305 HURSTBOURNE VILLAGE DR STE 600
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40299-2875
Country	:	US
Telephone Number	:	626-840-0111
Fax Number	:	626-270-4640

Provider Business Practice Location Address
First Line	:	2305 HURSTBOURNE VILLAGE DR STE 600
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40299-2875
Country	:	US
Telephone Number	:	626-840-0111
Fax Number	:	626-270-4640

Authorized Official
Title or Position	:	PROGRAM DIRECTOR
Name	:	MR. JORDAN T. DESIMONE
Credential	:	CADC-CAS
Telephone Number	:	626-808-0335

Provider Enumeration Date	:	09/11/2018
Last Update Date	:	09/11/2018

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Directions to “PAX HOUSE INC. ” Practice Location

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