Provider Demographics
NPI:1295276145
Name:WAIDE PHYSICAL THERAPY PSC
Entity type:Organization
Organization Name:WAIDE PHYSICAL THERAPY PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / CEO
Authorized Official - Prefix:
Authorized Official - First Name:FORREST
Authorized Official - Middle Name:
Authorized Official - Last Name:WAIDE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:270-871-7503
Mailing Address - Street 1:2228 ANTON RD
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431-7700
Mailing Address - Country:US
Mailing Address - Phone:270-399-1776
Mailing Address - Fax:270-440-2007
Practice Address - Street 1:2228 ANTON RD
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-7700
Practice Address - Country:US
Practice Address - Phone:270-399-1776
Practice Address - Fax:270-440-2007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-12
Last Update Date:2017-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY100110300542251H1200X
KY13202251X0800X
KY001533225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No2251H1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHandGroup - Single Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty