Provider Demographics
NPI:1699361188
Name:ROSS, SERENE E
Entity type:Individual
Prefix:
First Name:SERENE
Middle Name:E
Last Name:ROSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4169 WESTPORT RD STE 124
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-2747
Mailing Address - Country:US
Mailing Address - Phone:502-558-6818
Mailing Address - Fax:
Practice Address - Street 1:4169 WESTPORT RD STE 124
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-2747
Practice Address - Country:US
Practice Address - Phone:502-558-6818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-18
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYAC084171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY6050OtherALL INSURANCE