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General NPI Number Information
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NPI Number | 1063168623
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Entity Type | Organization
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Legal Business Name | GERIACTIVE
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Dates
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Enumeration Date | 02/22/2022
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Last Update Date | 03/15/2022
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Provider Practice Location Address
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Address Line | 335 STREAMLAND DR
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City | DANVILLE
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State | KY
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Zip | 40422-1081
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Country | US
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Telephone | 606-424-7483
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1872
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City | DANVILLE
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State | KY
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Zip | 40423-1872
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER/PHYSICAL THERAPIST
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Name | DR. AMANDA PRUITT
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Credential | PT, DPT
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Telephone | 606-424-7483
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number |
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License Number State |
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