Basic Information
| Provider Information | |||||||||
| NPI: | 1114000478 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VAACA OF KENTUCKY PSC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ALLERGY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1261 GOSS AVE | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402171239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026356937 | ||||||||
| FaxNumber: | 5026343926 | ||||||||
| Practice Location | |||||||||
| Address1: | 1261 GOSS AVE | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402171239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026356937 | ||||||||
| FaxNumber: | 5026343926 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 08/02/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NOAH | ||||||||
| AuthorizedOfficialFirstName: | BECKY | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5026356937 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CMM | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Allergy & Immunology |
ID Information
| ID | Type | State | Issuer | Description | 65928889 | 05 | KY | MEDICAID |