=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770105223
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ERVIN PHYSICAL THERAPY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2020
-----------------------------------------------------
Last Update Date | 10/08/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 129 N MORGAN STREET
-----------------------------------------------------
City | MORGANFIELD
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-997-0433
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 129 N MORGAN STREET
-----------------------------------------------------
City | MORGANFIELD
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST/OWNER
-----------------------------------------------------
Name | DR. ISAAC WAYNE ERVIN
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 270-873-4685
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------