Provider Demographics
NPI:1679669600
Name:BLUE GRASS PHYSIOTHERAPY, PLLC
Entity Type:Organization
Organization Name:BLUE GRASS PHYSIOTHERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:LOZE
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICAL THERAPIST
Authorized Official - Phone:606-678-5708
Mailing Address - Street 1:117 TRADEPARK DR
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-3428
Mailing Address - Country:US
Mailing Address - Phone:606-678-5708
Mailing Address - Fax:606-678-4336
Practice Address - Street 1:117 TRADEPARK DR
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-3428
Practice Address - Country:US
Practice Address - Phone:606-678-5708
Practice Address - Fax:606-678-4336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2020-08-22
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
KY64-00220OtherUHC PROVIDER NUMBERS
KY64-00220OtherUHC PROVIDER NUMBERS