| Park Duvalle Mobile Dentistry Van | |
|
3015 Wilson Ave Louisville KY 40211-1969 | |
| (502) 916-7091 | |
| Not Available |
| Full Name | Park Duvalle Mobile Dentistry Van |
|---|---|
| Speciality | Clinic/center - Federally Qualified Health Center (fqhc) |
| Location | 3015 Wilson Ave, Louisville, Kentucky |
| Authorized Official Name and Position | Swannie Jett (CEO) |
| Authorized Official Contact | 5027744401 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Park Duvalle Mobile Dentistry Van 3015 Wilson Ave Louisville KY 40211-1969 Ph: (502) 774-4401 | Park Duvalle Mobile Dentistry Van 3015 Wilson Ave Louisville KY 40211-1969 Ph: (502) 916-7091 |
| NPI Number | 1275151292 |
|---|---|
| Provider Enumeration Date | 07/07/2020 |
| Last Update Date | 11/02/2021 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1275151292 | NPI | - | NPPES |
| 7100595370 | Medicaid | KY | |
| 31000011 | Medicaid | KY | |
| 31000920 | Medicaid | KY |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | (* (Not Available)) | Primary |
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