Basic Information
| Provider Information | |||||||||
| NPI: | 1477726909 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WESTERN KENTUCKY ORTHOPAEDIC ASSOCIATES REHABILITATION DEPARTMENT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1777 ASHLEY CIR | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421043339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707930395 | ||||||||
| FaxNumber: | 2707930765 | ||||||||
| Practice Location | |||||||||
| Address1: | 1777 ASHLEY CIR | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421043339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707930395 | ||||||||
| FaxNumber: | 2707930765 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2008 | ||||||||
| LastUpdateDate: | 04/04/2008 | ||||||||
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| AuthorizedOfficialLastName: | LEAR | ||||||||
| AuthorizedOfficialFirstName: | BRAD | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROGRAM DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2707930395 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WESTERN KENTUCKY ORTHOPAEDIC ASSOCIATES | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | P.T. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT-003058 | KY | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT-004206 | KY | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225X00000X | R2545 | KY | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | R3434 | KY | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | PT-003526 | KY | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.