Healthcare Provider Details

I. General information

NPI: 1396218798
Provider Name (Legal Business Name): SN KENTUCKIANA REHAB, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2019
Last Update Date: 02/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 COPPERFIELD DR
GEORGETOWN IN
47122-9075
US

IV. Provider business mailing address

4714 GETTYSBURG RD
MECHANICSBURG PA
17055-4325
US

V. Phone/Fax

Practice location:
  • Phone: 502-499-0107
  • Fax: 502-499-0535
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL TARVIN
Title or Position: VICE PRESIDENT
Credential:
Phone: 717-972-1100