Provider Demographics
NPI:1891388310
Name:CHIROPRACTIC REHAB AND SPORTS INJURIES OF LOUISVILLE
Entity Type:Organization
Organization Name:CHIROPRACTIC REHAB AND SPORTS INJURIES OF LOUISVILLE
Other - Org Name:CHIROPRACTIC, REHAB, AND SPORTS INJURIES OF LOUISVILLE LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:606-564-4213
Mailing Address - Street 1:4106 FLINTLOCK DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40216-1534
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:502-688-6468
Practice Address - Street 1:4106 FLINTLOCK DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-1534
Practice Address - Country:US
Practice Address - Phone:502-290-7361
Practice Address - Fax:502-688-6468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-16
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100405870Medicaid