Provider Demographics
NPI:1982197737
Name:LOUISVILLE CENTER FOR EATING DISORDERS LLC
Entity Type:Organization
Organization Name:LOUISVILLE CENTER FOR EATING DISORDERS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:BRENT
Authorized Official - Last Name:WALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:502-319-3105
Mailing Address - Street 1:11824 RANSUM DR STE 200
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40243-2802
Mailing Address - Country:US
Mailing Address - Phone:502-338-0608
Mailing Address - Fax:502-245-1888
Practice Address - Street 1:11824 RANSUM DR # 200
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40243-2802
Practice Address - Country:US
Practice Address - Phone:502-338-0608
Practice Address - Fax:502-245-1888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-07
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty