Healthcare Provider Details

I. General information

NPI: 1629218771
Provider Name (Legal Business Name): MELODY PRINKLETON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2009
Last Update Date: 03/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4103 BOLLLING BROOK DRIVE
LOUISVILLE KY
40299
US

IV. Provider business mailing address

PO BOX 99977
LOUISVILLE KY
40269-0977
US

V. Phone/Fax

Practice location:
  • Phone: 502-212-5103
  • Fax: 502-212-5103
Mailing address:
  • Phone: 502-212-5103
  • Fax: 502-749-2226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number003948
License Number StateKY

VIII. Authorized Official

Name: MELODY PRINKLETON
Title or Position: PHYSICAL THERAPIST/OWNER
Credential: PT, DPT
Phone: 502-212-5103