Provider Demographics
NPI:1114403060
Name:CHAMPION PHYSICAL THERAPY KENTUCKY, LLC
Entity Type:Organization
Organization Name:CHAMPION PHYSICAL THERAPY KENTUCKY, LLC
Other - Org Name:CORA PHYSICAL THERAPY - MIDDLESBORO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:C
Authorized Official - Last Name:ROUSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-221-6712
Mailing Address - Street 1:1110 SHAWNEE RD
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805-3529
Mailing Address - Country:US
Mailing Address - Phone:419-221-6720
Mailing Address - Fax:419-222-0507
Practice Address - Street 1:1475 US HIGHWAY 25 E STE 6
Practice Address - Street 2:
Practice Address - City:MIDDLESBORO
Practice Address - State:KY
Practice Address - Zip Code:40965-2077
Practice Address - Country:US
Practice Address - Phone:606-248-1996
Practice Address - Fax:606-248-1901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-13
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation