Provider Demographics
NPI:1609818434
Name:ZOOM GROUP
Entity Type:Organization
Organization Name:ZOOM GROUP
Other - Org Name:ZOOM GROUP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:QUALITY ASSURANCE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-581-0658
Mailing Address - Street 1:1904 EMBASSY SQUARE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299
Mailing Address - Country:US
Mailing Address - Phone:502-581-0658
Mailing Address - Fax:502-581-9520
Practice Address - Street 1:1904 EMBASSY SQUARE BLVD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299
Practice Address - Country:US
Practice Address - Phone:502-581-0658
Practice Address - Fax:502-581-9520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0216571251C00000X
KY750120251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY43000355Medicaid
KY33300393Medicaid