=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730562075
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOMERSET SPINE & PERFORMANCE PHYSIOTHERAPY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2015
-----------------------------------------------------
Last Update Date | 03/30/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 RICHIE LN STE A
-----------------------------------------------------
City | SOMERSET
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42503-6128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-425-4665
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 RICHIE LN STE A
-----------------------------------------------------
City | SOMERSET
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42503-6128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-425-4665
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER / PHYSICAL THERAPIST
-----------------------------------------------------
Name | JOSH HARRIS
-----------------------------------------------------
Credential | PT, DPT
-----------------------------------------------------
Telephone | 606-425-4665
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------