Basic Information
| Provider Information | |||||||||
| NPI: | 1861419319 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRISCOLA | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | BRIAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 W LINCOLN TRAIL BLVD STE 103 | ||||||||
| Address2: | |||||||||
| City: | RADCLIFF | ||||||||
| State: | KY | ||||||||
| PostalCode: | 401602671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2703521061 | ||||||||
| FaxNumber: | 2703521067 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 W LINCOLN TRAIL BLVD STE 103 | ||||||||
| Address2: | |||||||||
| City: | RADCLIFF | ||||||||
| State: | KY | ||||||||
| PostalCode: | 401602671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2703521061 | ||||||||
| FaxNumber: | 2703521067 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 12/28/2010 | ||||||||
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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 | 004308 | KY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 50000935 | 01 | KY | PASSPORT HEALTH | OTHER | 8700086500 | 05 | KY | MEDICAID | 000000238482 | 01 | KY | BCBS | OTHER | 1861419319 | 01 | KY | RAIL ROAD MEDICARE | OTHER |