Provider Demographics
NPI:1730357419
Name:CENTRAL KENTUCKY MOBILITY OF LOUISVILLE, LLC
Entity type:Organization
Organization Name:CENTRAL KENTUCKY MOBILITY OF LOUISVILLE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:PRESTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-225-3624
Mailing Address - Street 1:1050 ENTERPRISE DR STE 125
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40510-1014
Mailing Address - Country:US
Mailing Address - Phone:859-225-3624
Mailing Address - Fax:859-225-3682
Practice Address - Street 1:11700 COMMONWEALTH DR STE 900
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-6357
Practice Address - Country:US
Practice Address - Phone:859-266-9061
Practice Address - Fax:859-266-6251
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTRAL KENTUCKY MOBILITY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-14
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY7100125720332B00000X
KY282426332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY45001658Medicaid
KY90005653Medicaid
KY6230620001Medicare NSC