Organization
KENTUCKY LIFE SOURCE INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JACQUELINE SANDERS (CREDENTIALING ADMIN)
(502) 365-3394
Entity
Organization
Contact information
Practice address
2619 W BROADWAY, LOUISVILLE, KY 40211-1332
(502) 303-7665
Mailing address
2619 W BROADWAY, LOUISVILLE, KY 40211-1332
(502) 303-7665
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
—
—
Other
Enumeration date
03/04/2024
Last updated
03/13/2025
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