=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871961987
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILLIAM NEICE PTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2015
-----------------------------------------------------
Last Update Date | 09/04/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 125 CALHOUN RD
-----------------------------------------------------
City | OLIVE HILL
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41164-5933
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-738-4636
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 125 CALHOUN RD
-----------------------------------------------------
City | OLIVE HILL
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41164-5933
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-738-4636
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | A03062
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------