Basic Information
| Provider Information | |||||||||
| NPI: | 1730357419 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL KENTUCKY MOBILITY OF LOUISVILLE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1050 ENTERPRISE DR STE 125 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405101014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592253624 | ||||||||
| FaxNumber: | 8592253682 | ||||||||
| Practice Location | |||||||||
| Address1: | 11700 COMMONWEALTH DR STE 900 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402996357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592669061 | ||||||||
| FaxNumber: | 8592666251 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2008 | ||||||||
| LastUpdateDate: | 12/06/2010 | ||||||||
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| AuthorizedOfficialLastName: | PRESTON | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | GENERAL MANAGER/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8592253624 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CENTRAL KENTUCKY MOBILITY, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 7100125720 | KY | N | Suppliers | Durable Medical Equipment & Medical Supplies | 332BC3200X | 282426 | KY | Y | Suppliers | Durable Medical Equipment & Medical Supplies | Customized Equipment |
ID Information
| ID | Type | State | Issuer | Description | 45001658 | 05 | KY | MEDICAID | 90005653 | 05 | KY | MEDICAID |