Basic Information
| Provider Information | |||||||||
| NPI: | 1124328323 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KENTUCKY PHS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1509 DULLES DRIVE | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3379919276 | ||||||||
| FaxNumber: | 3379430846 | ||||||||
| Practice Location | |||||||||
| Address1: | 4965 US HIGHWAY 42 STE 1000 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402226375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3379919276 | ||||||||
| FaxNumber: | 3379430846 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2010 | ||||||||
| LastUpdateDate: | 07/08/2020 | ||||||||
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| AuthorizedOfficialLastName: | HOWARD | ||||||||
| AuthorizedOfficialFirstName: | NICOLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3379919276 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PROVIDER HEALTH SERVICES LLC | ||||||||
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| NPICertificationDate: | 07/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 7100163370 | 05 | KY | MEDICAID |