Provider Demographics
NPI:1588610513
Name:LIBERTY REHABILITATION PSC
Entity Type:Organization
Organization Name:LIBERTY REHABILITATION PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:FORREST
Authorized Official - Middle Name:L
Authorized Official - Last Name:WAIDE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:270-824-9227
Mailing Address - Street 1:100 YMCA DR
Mailing Address - Street 2:SUITE 5
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431-9000
Mailing Address - Country:US
Mailing Address - Phone:270-824-9227
Mailing Address - Fax:270-824-9206
Practice Address - Street 1:100 YMCA DR
Practice Address - Street 2:SUITE 5
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-9000
Practice Address - Country:US
Practice Address - Phone:270-824-9227
Practice Address - Fax:270-824-9206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2012-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY225100000X, 2251H1200X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No2251H1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHandGroup - Single Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000477211OtherANTHEM FACET GROUP #
KY000000477211OtherANTHEM FACET GROUP #