Provider Demographics
NPI:1982686887
Name:MONTICELLO PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:MONTICELLO PHYSICAL THERAPY INC
Other - Org Name:WAYNE COUNTY PHYSICAL THERAPY CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:M
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:606-348-3314
Mailing Address - Street 1:1 S CREEK DR
Mailing Address - Street 2:SUITE 116
Mailing Address - City:MONTICELLO
Mailing Address - State:KY
Mailing Address - Zip Code:42633-9472
Mailing Address - Country:US
Mailing Address - Phone:606-348-3314
Mailing Address - Fax:606-348-3315
Practice Address - Street 1:ONE SOUTHCREEK DR
Practice Address - Street 2:SUITE 116
Practice Address - City:MONTICELLO
Practice Address - State:KY
Practice Address - Zip Code:42633-9472
Practice Address - Country:US
Practice Address - Phone:606-348-3314
Practice Address - Fax:606-348-3315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY225100000X
261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY87900353Medicaid
X67629Medicare UPIN
KY8856Medicare ID - Type Unspecified