Healthcare Provider Details

I. General information

NPI: 1386281269
Provider Name (Legal Business Name): WESLEY CRAIG LAUDERBACK MSPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2019
Last Update Date: 03/10/2020
Certification Date: 03/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8985 OHIO RIVER RD
WHEELERSBURG OH
45694-1923
US

IV. Provider business mailing address

2700 GREENUP AVE
ASHLAND KY
41101-1953
US

V. Phone/Fax

Practice location:
  • Phone: 740-456-6666
  • Fax:
Mailing address:
  • Phone: 606-324-0540
  • Fax: 606-324-0616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number011665
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: