Provider Demographics
NPI:1568461143
Name:SCOTT COUNTY PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:SCOTT COUNTY PHYSICAL THERAPY, LLC
Other - Org Name:SCOTT COUNTY PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACLYN
Authorized Official - Middle Name:L
Authorized Official - Last Name:TEVELDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-863-4242
Mailing Address - Street 1:208 BEVINS LANE
Mailing Address - Street 2:#F
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324
Mailing Address - Country:US
Mailing Address - Phone:502-863-4242
Mailing Address - Fax:502-570-9813
Practice Address - Street 1:208 BEVINS LANE
Practice Address - Street 2:#F
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324
Practice Address - Country:US
Practice Address - Phone:502-863-4242
Practice Address - Fax:502-570-9813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-18
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100036150Medicaid