MEDICARE: FERN CREEK TRADITIONAL HIGH SCHOOL

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	305S00000X	Point of Service	AT445	KY

General Provider Information

NPI Number	:	1871623520
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FERN CREEK TRADITIONAL HIGH SCHOOL

Provider Business Mailing Address
First Line	:	195 AULBERN DR E
Second Line	:
City	:	MT WASHINGTON
State	:	KY
Zip	:	40047-6300
Country	:	US
Telephone Number	:	502-553-0470
Fax Number	:	502-485-8009

Provider Business Practice Location Address
First Line	:	9115 FERN CREEK RD
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40291-2711
Country	:	US
Telephone Number	:	502-553-0470
Fax Number	:	502-485-8009

Authorized Official
Title or Position	:	ATHLETIC DIRECTOR
Name	:	MR. TIMOTHY P AMSHOFF
Credential	:
Telephone Number	:	502-538-4951

Provider Enumeration Date	:	03/06/2007
Last Update Date	:	08/22/2020

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