Provider Demographics
NPI:1649060997
Name:COMMONWEALTH CORRECTIONAL CARE
Entity type:Organization
Organization Name:COMMONWEALTH CORRECTIONAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:HALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-524-2880
Mailing Address - Street 1:15402 CHAMPION LAKES PL
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40245-5601
Mailing Address - Country:US
Mailing Address - Phone:502-552-3879
Mailing Address - Fax:
Practice Address - Street 1:15402 CHAMPION LAKES PL
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40245-5601
Practice Address - Country:US
Practice Address - Phone:502-552-3879
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-09
Last Update Date:2025-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty