Healthcare Provider Details

I. General information

NPI: 1316739717
Provider Name (Legal Business Name): LILA GRACE SPAULDING PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2025
Last Update Date: 05/21/2025
Certification Date: 05/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 OTTO DR
INEZ KY
41224-8807
US

IV. Provider business mailing address

4009 HIGHWAY 581
ULYSSES KY
41264-9070
US

V. Phone/Fax

Practice location:
  • Phone: 606-298-4567
  • Fax: 606-298-7073
Mailing address:
  • Phone: 606-626-8689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA04617
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: