Provider Demographics
NPI:1952587719
Name:BLUEGRASS PHYSICAL THERAPY & REHABILITATION INC.
Entity Type:Organization
Organization Name:BLUEGRASS PHYSICAL THERAPY & REHABILITATION INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:
Authorized Official - Last Name:BROCKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSCIAL THERAPY
Authorized Official - Phone:859-371-1929
Mailing Address - Street 1:13 OBLIQUE ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41042-1927
Mailing Address - Country:US
Mailing Address - Phone:859-371-1929
Mailing Address - Fax:859-371-2581
Practice Address - Street 1:13 OBLIQUE ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-1927
Practice Address - Country:US
Practice Address - Phone:859-371-1929
Practice Address - Fax:859-371-2581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-11
Last Update Date:2009-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY001500174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY00672Medicare PIN