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NPI Code Detail

MEDICARE: CHARLES PEMBERTON JR.

MEDICARE: CHARLES PEMBERTON JR.
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
1101YP2500XProfessional Counselor1169KY

General Provider Information

NPI Number : 1629582531
Entity Type Code : Individual
Provider Name (Legal Business Name) : CHARLES PEMBERTON JR.
Provider Business Mailing Address
First Line : 2302 HURSTBOURNE VILLAGE DR STE 300
Second Line :
City : LOUISVILLE
State : KY
Zip : 40299-1843
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 2302 HURSTBOURNE VILLAGE DR STE 300
Second Line :
City : LOUISVILLE
State : KY
Zip : 40299-1843
Country : US
Telephone Number : 502-491-9720
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/30/2017
Last Update Date : 11/30/2017

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