Provider Demographics
NPI:1265723464
Name:SPECIALIZED PHYSICAL THERAPY, PLLC
Entity type:Organization
Organization Name:SPECIALIZED PHYSICAL THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:LUKE
Authorized Official - Last Name:KEACH
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:423-364-6183
Mailing Address - Street 1:6025 LEE HWY STE 445
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-2966
Mailing Address - Country:US
Mailing Address - Phone:423-499-4043
Mailing Address - Fax:423-499-4045
Practice Address - Street 1:6025 LEE HWY STE 445
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-2966
Practice Address - Country:US
Practice Address - Phone:423-499-4043
Practice Address - Fax:423-499-4045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-22
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003185128AMedicaid
TN1524405Medicaid
TN1524405Medicaid