Provider Demographics
NPI:1275151292
Name:PARK DUVALLE COMMUNITY HEALTH CENTER, INC
Entity Type:Organization
Organization Name:PARK DUVALLE COMMUNITY HEALTH CENTER, INC
Other - Org Name:PARK DUVALLE MOBILE DENTISTRY VAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SWANNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-774-4401
Mailing Address - Street 1:3015 WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40211-1969
Mailing Address - Country:US
Mailing Address - Phone:502-774-4401
Mailing Address - Fax:
Practice Address - Street 1:3015 WILSON AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40211-1969
Practice Address - Country:US
Practice Address - Phone:502-916-7091
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PARK DUVALLE COMMUNITY HEALTH CENTER, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-07-07
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100595370Medicaid
KY31000011Medicaid
KY31000920Medicaid