Healthcare Provider Details

I. General information

NPI: 1295962124
Provider Name (Legal Business Name): SMITHS GROVE PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2009
Last Update Date: 02/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 COLLEGE STREET
SMITHS GROVE KY
42171
US

IV. Provider business mailing address

PO BOX 157
BROWNSVILLE KY
42210-0157
US

V. Phone/Fax

Practice location:
  • Phone: 270-563-2084
  • Fax: 270-563-2085
Mailing address:
  • Phone: 270-563-2084
  • Fax: 270-563-2085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251E1300X
TaxonomyClinical Electrophysiology Physical Therapist
License Number004222
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number004222
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number004222
License Number StateKY
# 4
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number004222
License Number StateKY

VIII. Authorized Official

Name: MR. JEREMY LOGAN SCHAFER
Title or Position: OWNER/MEMBER
Credential: PT, OCS, ECS
Phone: 270-563-2084