Basic Information
Provider Information | |||||||||
NPI: | 1831234483 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ACTIVE DAY KY, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ACTIVE DAY OF LOUISVILLE HIKES POINT OPT | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 400 REDLAND CT | ||||||||
Address2: | SUITE 114 | ||||||||
City: | OWINGS MILLS | ||||||||
State: | MD | ||||||||
PostalCode: | 211173270 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4435482200 | ||||||||
FaxNumber: | 4435482260 | ||||||||
Practice Location | |||||||||
Address1: | 3403 BRECKENRIDGE LN | ||||||||
Address2: |   | ||||||||
City: | LOUISVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 402203101 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5028961444 | ||||||||
FaxNumber: | 5028930095 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/21/2007 | ||||||||
LastUpdateDate: | 12/19/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BALDOCK | ||||||||
AuthorizedOfficialFirstName: | KRIS | ||||||||
AuthorizedOfficialMiddleName: | W. | ||||||||
AuthorizedOfficialTitleorPosition: | CHAIRMAN, CEO, PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 4435482201 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | ACTIVE DAY INC. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
No ID Information.