Healthcare Provider Details

I. General information

NPI: 1306222849
Provider Name (Legal Business Name): DEACONESS PROGRESSIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2015
Last Update Date: 08/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8700A N KENTUCKY AVE
EVANSVILLE IN
47725-6308
US

IV. Provider business mailing address

150 N ROSENBERGER AVE
EVANSVILLE IN
47712-6503
US

V. Phone/Fax

Practice location:
  • Phone: 812-437-2893
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number05006175A
License Number StateIN

VIII. Authorized Official

Name: TINA MCKINNEY
Title or Position: PHYSICAL THERAPIST
Credential: PT
Phone: 812-612-0266