Healthcare Provider Details

I. General information

NPI: 1699198424
Provider Name (Legal Business Name): ORTHODYNE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2014
Last Update Date: 01/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 W. BROADWAY SUITE 103
CAMPBELLSVILLE KY
42718-2212
US

IV. Provider business mailing address

PO BOX 1430
FRANKFORT KY
40602-1430
US

V. Phone/Fax

Practice location:
  • Phone: 270-789-6629
  • Fax: 270-789-0424
Mailing address:
  • Phone: 502-226-3858
  • Fax: 502-223-9829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberR4686
License Number StateKY

VIII. Authorized Official

Name: PETER T. KIRSCH
Title or Position: PRESIDENT
Credential: M.D.
Phone: 270-789-6629