Provider Demographics
NPI:1942214663
Name:PARK DUVALLE COMMUNITY HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:PARK DUVALLE COMMUNITY HEALTH CENTER, INC.
Other - Org Name:PARK DUVALLE AT SPENCER COUNTY
Other - Org Type:Other Name
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:502-772-4783
Practice Address - Street 1:501 TAYLORSVILLE RD
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:KY
Practice Address - Zip Code:40071-6766
Practice Address - Country:US
Practice Address - Phone:502-477-2248
Practice Address - Fax:502-477-9356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY700005261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY31000920Medicaid
KY18-1825Medicare ID - Type Unspecified