Healthcare Provider Details

I. General information

NPI: 1457352007
Provider Name (Legal Business Name): ELIZABETHTOWN PHYSICAL THERAPY PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2005
Last Update Date: 03/11/2008
Certification Date:
Deactivation Date: 10/10/2006
Reactivation Date: 10/30/2006

III. Provider practice location address

815 FAIRWAY DR SUITE C
BRANDENBURG KY
40108
US

IV. Provider business mailing address

4716 OLD GETTYSBURG RD LEGAL DEPARTMENT
MECHANICSBURG PA
17055
US

V. Phone/Fax

Practice location:
  • Phone: 270-422-3366
  • Fax: 270-422-3378
Mailing address:
  • Phone: 717-975-4503
  • Fax: 717-975-9981

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. MICHAEL E TARVIN
Title or Position: VICE PRESIDENT
Credential:
Phone: 717-975-4503