=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417552506
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WINNING EDGE PHYSICAL THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2020
-----------------------------------------------------
Last Update Date | 12/04/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9310 KELCH RD
-----------------------------------------------------
City | VERSAILLES
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45380-9679
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 567-224-2045
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9310 KELCH RD
-----------------------------------------------------
City | VERSAILLES
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45380-9679
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHYSICAL THERAPIST
-----------------------------------------------------
Name | STEPHEN WINNER
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 937-564-1777
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------