Basic Information
| Provider Information | |||||||||
| NPI: | 1598817785 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENSON | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 403 N MILES ST | ||||||||
| Address2: | |||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427011834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2703609129 | ||||||||
| FaxNumber: | 2702348197 | ||||||||
| Practice Location | |||||||||
| Address1: | 4331 CHURCHMAN AVE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402151164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023661773 | ||||||||
| FaxNumber: | 5023663500 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 225100000X | 004602 | KY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 000000340690 | 01 | KY | BLUE CROSS | OTHER |