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3934 Dixie Hwy Ste 210 Louisville KY 40216-4176 | |
| (502) 794-3082 | |
| Not Available |
| Full Name | |
|---|---|
| Speciality | Substance Abuse Rehabilitation Facility |
| Location | 3934 Dixie Hwy Ste 210, Louisville, Kentucky |
| Authorized Official Name and Position | Claude Edward Johnson (EXECUTIVE DIRECTOR) |
| Authorized Official Contact | 5027943082 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
2312 S Preston St Unit 17567 Louisville KY 40217-5022 Ph: (502) 794-3082 | 3934 Dixie Hwy Ste 210 Louisville KY 40216-4176 Ph: (502) 794-3082 |
| NPI Number | 1922763861 |
|---|---|
| Provider Enumeration Date | 11/05/2021 |
| Last Update Date | 08/20/2024 |
| Certification Date | 08/20/2024 |
| Medicare PECOS PAC ID | 1456706480 |
|---|---|
| Medicare Enrollment ID | O20231011003724 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1922763861 | NPI | - | NPPES |
| 7100791560 | Medicaid | KY |
| Provider Name | Amber Jainia Wood |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1538616578 PECOS PAC ID: 7416244884 Enrollment ID: I20160928002387 |
| Provider Name | Beth A Glass |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1962952515 PECOS PAC ID: 9739467473 Enrollment ID: I20161031001717 |
| Provider Name | Claude Johnson |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1447797683 PECOS PAC ID: 2365897394 Enrollment ID: I20241204002201 |
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