Basic Information
| Provider Information | |||||||||
| NPI: | 1720747413 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INNOVAGE KENTUCKY PACE- LOUISVILLE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8950 E LOWRY BLVD | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802307030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3039127193 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6013 PRESTON HWY | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402191317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3038694664 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2021 | ||||||||
| LastUpdateDate: | 12/10/2021 | ||||||||
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| AuthorizedOfficialLastName: | WASHINGTON | ||||||||
| AuthorizedOfficialFirstName: | GAYLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3039127193 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251T00000X | Y | Agencies | PACE Provider Organization |
No ID Information.