Provider Demographics
NPI:1265578785
Name:ETA DAY CARE CENTER LLC
Entity type:Organization
Organization Name:ETA DAY CARE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:H
Authorized Official - Last Name:WALTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-776-7656
Mailing Address - Street 1:PO BOX 1051
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-1051
Mailing Address - Country:US
Mailing Address - Phone:502-776-7656
Mailing Address - Fax:502-776-7640
Practice Address - Street 1:724 SO 44TH STREET
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40211
Practice Address - Country:US
Practice Address - Phone:502-776-7656
Practice Address - Fax:502-776-7640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY750110251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY43000082Medicaid