1215935929 NPI number — WILLOWS OF SPRINGHURST OPCO, LLC

Table of content: (NPI 1215935929)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215935929 NPI number — WILLOWS OF SPRINGHURST OPCO, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILLOWS OF SPRINGHURST OPCO, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
THE WILLOWS AT SPRINGHURST
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215935929
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 221648
Provider Second Line Business Mailing Address:
ATTN LICENSURE
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40252-1648
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-412-5847
Provider Business Mailing Address Fax Number:
502-213-9977

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3001 N HURSTBOURNE PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40241-2209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-426-5531
Provider Business Practice Location Address Fax Number:
502-425-6988
Provider Enumeration Date:
07/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
CONNER
Authorized Official First Name:
GREG
Authorized Official Middle Name:
Authorized Official Title or Position:
SR. VICE PRESIDENT & TREASURER
Authorized Official Telephone Number:
502-412-5847

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  100513 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 12502134 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000054655 . This is a "ANTHEM HEALTH PLANS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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