=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104396449
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CORE PHYSICAL THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2018
-----------------------------------------------------
Last Update Date | 11/29/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 127 ALBEN BARKLEY DR STE C
-----------------------------------------------------
City | PADUCAH
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42001-4402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-908-0294
-----------------------------------------------------
Fax | 270-908-0296
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 127 ALBEN BARKLEY DR STE C
-----------------------------------------------------
City | PADUCAH
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42001-4402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-908-0294
-----------------------------------------------------
Fax | 270-908-0296
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST/OWNER
-----------------------------------------------------
Name | JEREMY WOODWARD
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 859-806-7218
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------