=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407071921
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TOTAL BODY REHAB PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2007
-----------------------------------------------------
Last Update Date | 12/17/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11330 MAPLE BROOK DR
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-412-5552
-----------------------------------------------------
Fax | 502-412-2234
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11330 MAPLE BROOK DR
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-412-5552
-----------------------------------------------------
Fax | 502-412-2234
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER PRESIDENT
-----------------------------------------------------
Name | ROBERT J POWRIE
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 502-412-5552
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 002453
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------