Basic Information
| Provider Information | |||||||||
| NPI: | 1962653964 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ACTIVE DAY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3403 BRECKENRIDGE LN | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402203101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028961444 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3403 BRECKENRIDGE LN | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402203101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028961444 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2008 | ||||||||
| LastUpdateDate: | 10/08/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MOBERLY | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | SUE | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 5028961444 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ACTIVE SERVICES | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | PT001369 | KY | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.