Provider Demographics
NPI:1518904333
Name:DEXTER PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:DEXTER PHYSICAL THERAPY LLC
Other - Org Name:PHYSICAL THERAPY PLUS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:N
Authorized Official - Last Name:DEXTER
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:270-526-9400
Mailing Address - Street 1:1416 MELROSE ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-3224
Mailing Address - Country:US
Mailing Address - Phone:270-526-9400
Mailing Address - Fax:270-526-9402
Practice Address - Street 1:811 S MAIN ST
Practice Address - Street 2:SUITE 12
Practice Address - City:MORGANTOWN
Practice Address - State:KY
Practice Address - Zip Code:42261-9400
Practice Address - Country:US
Practice Address - Phone:270-526-9400
Practice Address - Fax:270-526-9402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPT004206225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY87001541Medicaid
KY87001541Medicaid