Provider Demographics
NPI:1669967287
Name:FRESH ROUTES INCORPORATED
Entity type:Organization
Organization Name:FRESH ROUTES INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:MFT
Authorized Official - Phone:502-324-2199
Mailing Address - Street 1:743 E BROADWAY STE 291
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1711
Mailing Address - Country:US
Mailing Address - Phone:502-608-7640
Mailing Address - Fax:
Practice Address - Street 1:3146 W BROADWAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40211-1441
Practice Address - Country:US
Practice Address - Phone:502-776-0262
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-26
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)