Healthcare Provider Details

I. General information

NPI: 1538299540
Provider Name (Legal Business Name): SHAUN GOULBOURNE PHYSICAL THERAPIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1485 S DIXIE ST
HORSE CAVE KY
42749-1457
US

IV. Provider business mailing address

PO BOX 911148
LEXINGTON KY
40591-1148
US

V. Phone/Fax

Practice location:
  • Phone: 270-786-4551
  • Fax: 270-786-4551
Mailing address:
  • Phone: 859-278-2121
  • Fax: 859-276-1649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number002839
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: