Healthcare Provider Details

I. General information

NPI: 1851758148
Provider Name (Legal Business Name): KIRK MACDONALD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2016
Last Update Date: 01/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WURTLAND AVE
GREENUP KY
41144-1445
US

IV. Provider business mailing address

100 WURTLAND AVE
GREENUP KY
41144-1445
US

V. Phone/Fax

Practice location:
  • Phone: 606-836-0931
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA02138
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: