Basic Information
| Provider Information | |||||||||
| NPI: | 1164420683 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LOUISVILLE 02, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | AEROCARE HOME MEDICAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3325 BARTLETT BLVD | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328116428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4072060040 | ||||||||
| FaxNumber: | 4072060010 | ||||||||
| Practice Location | |||||||||
| Address1: | 112 HARDIN LN | ||||||||
| Address2: | |||||||||
| City: | SOMERSET | ||||||||
| State: | KY | ||||||||
| PostalCode: | 425033813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064922740 | ||||||||
| FaxNumber: | 8663127997 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2005 | ||||||||
| LastUpdateDate: | 07/27/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GRIGGS | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4072060040 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AEROCARE HOLDINGS LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 335E00000X | N | Suppliers | Prosthetic/Orthotic Supplier | 332B00000X | 049125 | KY | N | Suppliers | Durable Medical Equipment & Medical Supplies | 332BX2000X | MG0412 | KY | Y | Suppliers | Durable Medical Equipment & Medical Supplies | Oxygen Equipment & Supplies |
ID Information
| ID | Type | State | Issuer | Description | 7100127560 | 05 | KY | MEDICAID | 7444596 | 01 | KY | AETNA | OTHER | 000000330044 | 01 | KY | ANTHEM | OTHER | 1217887 | 01 | KY | CHA HEALTH PROVIDER ID | OTHER | 200500200A | 05 | IN | MEDICAID | 50004493 | 01 | KY | PASSPORT PROVIDER ID | OTHER |