Healthcare Provider Details

I. General information

NPI: 1134771405
Provider Name (Legal Business Name): ROGER LANE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2019
Last Update Date: 07/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 HIGHWAY 127 N
OWENTON KY
40359-9302
US

IV. Provider business mailing address

905 HIGHWAY 127 N
OWENTON KY
40359-9302
US

V. Phone/Fax

Practice location:
  • Phone: 502-484-5721
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number007226
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: