Provider Demographics
NPI:1508928300
Name:MAX PERFORMANCE PHYSICAL THERAPY AND SPORTS REHAB, LLC
Entity Type:Organization
Organization Name:MAX PERFORMANCE PHYSICAL THERAPY AND SPORTS REHAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:
Authorized Official - Last Name:CREQUE
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:502-647-0133
Mailing Address - Street 1:141 STONECREST RD
Mailing Address - Street 2:UNIT 2
Mailing Address - City:SHELBYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40065-8166
Mailing Address - Country:US
Mailing Address - Phone:502-647-0133
Mailing Address - Fax:502-647-0138
Practice Address - Street 1:141 STONECREST RD
Practice Address - Street 2:UNIT 2
Practice Address - City:SHELBYVILLE
Practice Address - State:KY
Practice Address - Zip Code:40065
Practice Address - Country:US
Practice Address - Phone:502-647-0133
Practice Address - Fax:502-647-0138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY004464225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0767001Medicare PIN
KYS70896Medicare UPIN