Provider Demographics
NPI:1295962124
Name:SMITHS GROVE PHYSICAL THERAPY
Entity type:Organization
Organization Name:SMITHS GROVE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:LOGAN
Authorized Official - Last Name:SCHAFER
Authorized Official - Suffix:
Authorized Official - Credentials:PT, OCS, ECS
Authorized Official - Phone:270-563-2084
Mailing Address - Street 1:PO BOX 157
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42210-0157
Mailing Address - Country:US
Mailing Address - Phone:270-563-2084
Mailing Address - Fax:270-563-2085
Practice Address - Street 1:111 COLLEGE STREET
Practice Address - Street 2:
Practice Address - City:SMITHS GROVE
Practice Address - State:KY
Practice Address - Zip Code:42171
Practice Address - Country:US
Practice Address - Phone:270-563-2084
Practice Address - Fax:270-563-2085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-18
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0042222251E1300X, 2251S0007X, 2251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No2251E1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistElectrophysiology, ClinicalGroup - Single Specialty
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Single Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY01055Medicare UPIN