Provider Demographics
NPI:1265616825
Name:SIGNATURE PROVIDER SERVICES LLC
Entity type:Organization
Organization Name:SIGNATURE PROVIDER SERVICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-568-7338
Mailing Address - Street 1:9815 BROWNSBORO RD
Mailing Address - Street 2:SUITE #102
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-1125
Mailing Address - Country:US
Mailing Address - Phone:502-568-7338
Mailing Address - Fax:502-568-7954
Practice Address - Street 1:9815 BROWNSBORO RD
Practice Address - Street 2:SUITE #102
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-1125
Practice Address - Country:US
Practice Address - Phone:502-568-7800
Practice Address - Fax:502-568-7150
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SIGNATURE HEALTHCARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-19
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332BN1400X, 332BP3500X
IN69001112A332B00000X
KY332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100227900Medicaid
KY6703890001Medicare NSC