Provider Demographics
NPI:1154794147
Name:PROVIDENCE OF LOUISVILLE LLC
Entity type:Organization
Organization Name:PROVIDENCE OF LOUISVILLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:W
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-802-7636
Mailing Address - Street 1:17014 ASHBURTON DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40245-5713
Mailing Address - Country:US
Mailing Address - Phone:502-689-2106
Mailing Address - Fax:
Practice Address - Street 1:17014 ASHBURTON DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40245-5713
Practice Address - Country:US
Practice Address - Phone:502-689-2106
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-12
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health