| Full Name | |
|---|---|
| Speciality | Clinic/Center |
| Location | 4205 Dixie Hwy, Louisville, Kentucky |
| Authorized Official Name and Position | Cassandra Nelson (OWNER) |
| Authorized Official Contact | 7147865227 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
4205 Dixie Hwy Louisville KY 40216 Ph: (714) 786-5227 | 4205 Dixie Hwy Louisville KY 40216 Ph: (714) 786-5227 |
| NPI Number | 1811736374 |
|---|---|
| Provider Enumeration Date | 05/23/2024 |
| Last Update Date | 05/23/2024 |
| Certification Date | 05/23/2024 |
| Medicare PECOS PAC ID | 3678013851 |
|---|---|
| Medicare Enrollment ID | O20240914000139 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1811736374 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YA0400X | Counselor - Addiction (substance Use Disorder) | (* (Not Available)) | Secondary |
| 261QM1300X | Clinic/center - Multi-specialty | (* (Not Available)) | Primary |
| Provider Name | Roberto A Penne-casanova |
|---|---|
| Provider Type | Practitioner - Preventive Medicine |
| Provider Identifiers | NPI Number: 1265492748 PECOS PAC ID: 4880581164 Enrollment ID: I20101119000610 |
| Provider Name | Keiosha Townsend |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1861878100 PECOS PAC ID: 3870895832 Enrollment ID: I20160107001393 |
| Provider Name | Miranda J Lewis |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1215633862 PECOS PAC ID: 9931572856 Enrollment ID: I20230223002016 |
| Provider Name | Magdalen K Mekoh |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1972387991 PECOS PAC ID: 2264886571 Enrollment ID: I20230920002025 |
| Provider Name | Lisa Jeanell Taylor |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1245760826 PECOS PAC ID: 3173975505 Enrollment ID: I20240122000627 |
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