Healthcare Provider Details

I. General information

NPI: 1992853782
Provider Name (Legal Business Name): CAROL FAIRCHILD PTA, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CAROL FLOYD MA, ATC

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 08/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 KIMBERLY LN
WILLIAMSTOWN KY
41097-9458
US

IV. Provider business mailing address

1811 WHISPERING TRL
UNION KY
41091-9539
US

V. Phone/Fax

Practice location:
  • Phone: 859-824-7803
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA03092
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number089502532
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: