=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265758718
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RECOVERY REHABILITATION LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2010
-----------------------------------------------------
Last Update Date | 04/08/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2600 W BROADWAY STE 208
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40211-1370
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-742-2300
-----------------------------------------------------
Fax | 502-742-2032
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2600 W BROADWAY STE 208
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40211-1370
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-742-2300
-----------------------------------------------------
Fax | 502-742-2032
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. WESLEY M GARRISON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 502-432-6574
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | R1864
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------