Provider Demographics
NPI:1912054602
Name:YMCA OF GREATER LOUISVILLE
Entity Type:Organization
Organization Name:YMCA OF GREATER LOUISVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:TARVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-587-9622
Mailing Address - Street 1:545 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1801
Mailing Address - Country:US
Mailing Address - Phone:502-587-9622
Mailing Address - Fax:502-587-4323
Practice Address - Street 1:2800 FORDHAVEN RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40214-3960
Practice Address - Country:US
Practice Address - Phone:502-933-9622
Practice Address - Fax:502-933-6309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY750124261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY56023898Medicaid
KY56025018Medicaid
KY43000280Medicaid