=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326574112
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PERRY JONATHAN ARNETT PTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2017
-----------------------------------------------------
Last Update Date | 05/11/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1939 ALMA CT
-----------------------------------------------------
City | MADISONVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42431-9505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-836-3373
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 122 W UNION ST
-----------------------------------------------------
City | HARTFORD
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42347-1416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-298-3112
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | A00741
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------