Provider Demographics
NPI:1184625113
Name:KENTUCKY ORTHOPEDIC REHABILITATION LLC
Entity type:Organization
Organization Name:KENTUCKY ORTHOPEDIC REHABILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:TARVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-972-1100
Mailing Address - Street 1:4714 GETTYSBURG RD
Mailing Address - Street 2:LEGAL DEPARTMENT
Mailing Address - City:MECHANICSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17055-4325
Mailing Address - Country:US
Mailing Address - Phone:717-972-1100
Mailing Address - Fax:717-975-9981
Practice Address - Street 1:210 E GRAY ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3900
Practice Address - Country:US
Practice Address - Phone:502-587-9350
Practice Address - Fax:502-587-9351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-01
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X, 335E00000X, 261QR0400X
KY261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY186591Medicare Oscar/Certification