Basic Information
| Provider Information | |||||||||
| NPI: | 1164077988 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DARNELL | ||||||||
| FirstName: | JEREMY | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 196 LOVERS LN APT B | ||||||||
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| City: | GLASGOW | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421415014 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 201 PARK ST | ||||||||
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| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421011742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707800552 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2019 | ||||||||
| LastUpdateDate: | 08/08/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | A03985 | KY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.