Healthcare Provider Details

I. General information

NPI: 1134804560
Provider Name (Legal Business Name): ERIC HENRY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2023
Last Update Date: 06/21/2023
Certification Date: 06/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 MERIDIAN HILLS DR
LOUISVILLE KY
40243-2234
US

IV. Provider business mailing address

61 STONE CREST DR
FISHERVILLE KY
40023-7402
US

V. Phone/Fax

Practice location:
  • Phone: 502-245-0655
  • Fax:
Mailing address:
  • Phone: 502-235-7137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA02399
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: