Provider Demographics
NPI:1164787958
Name:AGAPE COMMUNITY LIVING LLC
Entity Type:Organization
Organization Name:AGAPE COMMUNITY LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:VIBBERT
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN
Authorized Official - Phone:502-749-3257
Mailing Address - Street 1:4200 WALLINGFORD LN
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40218-2720
Mailing Address - Country:US
Mailing Address - Phone:502-749-3257
Mailing Address - Fax:502-742-3141
Practice Address - Street 1:4200 WALLINGFORD LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-2720
Practice Address - Country:US
Practice Address - Phone:502-749-3257
Practice Address - Fax:502-742-3141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-09
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY251S00000X320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1154568467Medicaid