Provider Demographics
NPI:1851751473
Name:PROFESSIONAL PHYSICAL THERAPY CLINIC LLC
Entity Type:Organization
Organization Name:PROFESSIONAL PHYSICAL THERAPY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:MORRICE
Authorized Official - Last Name:NANKWENYA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-712-1749
Mailing Address - Street 1:3415 BARDSTOWN RD STE 307
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40218-4633
Mailing Address - Country:US
Mailing Address - Phone:502-712-1749
Mailing Address - Fax:
Practice Address - Street 1:3415 BARDSTOWN RD STE 307
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-4633
Practice Address - Country:US
Practice Address - Phone:502-712-1749
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-24
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy