Provider Demographics
NPI:1942203955
Name:LIFESCAN OF LOUISVILLE LLC
Entity Type:Organization
Organization Name:LIFESCAN OF LOUISVILLE LLC
Other - Org Name:LIFESCAN LOUISVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTRACT MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-403-1401
Mailing Address - Street 1:4046 DUTCHMANS LN
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4712
Mailing Address - Country:US
Mailing Address - Phone:502-893-7145
Mailing Address - Fax:502-893-7147
Practice Address - Street 1:4046 DUTCHMANS LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4712
Practice Address - Country:US
Practice Address - Phone:502-893-7145
Practice Address - Fax:502-893-7147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65933764Medicaid
KY7100041020Medicaid
KY9365601Medicare PIN