1427671700 NPI number — SOUTHSIDE PERSONAL CARE HOME LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427671700 NPI number — SOUTHSIDE PERSONAL CARE HOME LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHSIDE PERSONAL CARE HOME 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:
Provider Other Organization Name Type Code:
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:
1427671700
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/07/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5330 S 3RD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40214-2680
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-533-1492
Provider Business Mailing Address Fax Number:
502-212-9292

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5330 S 3RD ST
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:
40214-2680
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-533-1492
Provider Business Practice Location Address Fax Number:
502-212-9292
Provider Enumeration Date:
05/21/2020

Additional Information

Authorized Official

Authorized Official Last Name:
KANYARE
Authorized Official First Name:
ABDIRASHID
Authorized Official Middle Name:
AHMED
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
502-533-1492

Provider Taxonomy Codes

  • Taxonomy code: 374U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 500334 . This is a "CABINET FOR HEALTH AND FAMILY SERVICES OFFICE OF INSPECTOR GENERAL" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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