Provider Demographics
NPI:1851693162
Name:GREAT OUTCOMES PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:GREAT OUTCOMES PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-912-1081
Mailing Address - Street 1:40 UTZ DR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41042-1539
Mailing Address - Country:US
Mailing Address - Phone:859-912-1081
Mailing Address - Fax:859-305-1668
Practice Address - Street 1:40 UTZ DR
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-1539
Practice Address - Country:US
Practice Address - Phone:859-912-1081
Practice Address - Fax:859-305-1668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-19
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY001647252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes252Y00000XAgenciesEarly Intervention Provider AgencyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY107262010000108Medicare PIN