Provider Demographics
NPI:1477714855
Name:PRIDEMORE, KEVIN M (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:PRIDEMORE
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 950248
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0248
Mailing Address - Country:US
Mailing Address - Phone:502-489-5730
Mailing Address - Fax:502-489-5753
Practice Address - Street 1:1051 NEWTOWN PIKE
Practice Address - Street 2:SUITE H-J
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40511
Practice Address - Country:US
Practice Address - Phone:859-253-0758
Practice Address - Fax:859-253-0890
Is Sole Proprietor?:No
Enumeration Date:2008-06-19
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY004120225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist