=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568717445
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DERBY CITY REHAB
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2012
-----------------------------------------------------
Last Update Date | 07/17/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1300 S 4TH ST SUITE 240
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40208-2314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-634-3540
-----------------------------------------------------
Fax | 502-634-3566
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1300 S 4TH ST SUITE 240
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40208-2314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-634-3540
-----------------------------------------------------
Fax | 502-634-3566
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | JENNIFER FAITH MARCO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 502-634-3540
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------