Provider Demographics
NPI:1720747413
Name:INNOVAGE KENTUCKY PACE- LOUISVILLE, LLC
Entity Type:Organization
Organization Name:INNOVAGE KENTUCKY PACE- LOUISVILLE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GAYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:WASHINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-912-7193
Mailing Address - Street 1:8950 E LOWRY BLVD
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80230-7030
Mailing Address - Country:US
Mailing Address - Phone:303-912-7193
Mailing Address - Fax:
Practice Address - Street 1:6013 PRESTON HWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-1317
Practice Address - Country:US
Practice Address - Phone:303-869-4664
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-10
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization