Basic Information
| Provider Information | |||||||||
| NPI: | 1225061542 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TOTAL REHAB CENTER, PSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 175 MEDPARK DRIVE | ||||||||
| Address2: | |||||||||
| City: | SOMERSET | ||||||||
| State: | KY | ||||||||
| PostalCode: | 425032888 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6066791761 | ||||||||
| FaxNumber: | 6066780971 | ||||||||
| Practice Location | |||||||||
| Address1: | 175 MEDPARK DRIVE | ||||||||
| Address2: | |||||||||
| City: | SOMERSET | ||||||||
| State: | KY | ||||||||
| PostalCode: | 425032888 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6066791761 | ||||||||
| FaxNumber: | 6066780971 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 03/01/2016 | ||||||||
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| AuthorizedOfficialLastName: | RANDALL | ||||||||
| AuthorizedOfficialFirstName: | TERRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6066791761 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225400000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | 225XP0019X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Physical Rehabilitation | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 87031803 | 05 | KY | MEDICAID | 000000225875 | 01 | KY | BCBS GROUP NUMBER FOR PT | OTHER |