=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891511069
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ATHLETICO LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/03/2024
-----------------------------------------------------
Last Update Date | 12/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12935 SHELBYVILLE RD STE 107
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40243-1592
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-792-8900
-----------------------------------------------------
Fax | 502-537-6378
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2122 YORK RD STE 300
-----------------------------------------------------
City | OAK BROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60523-1925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-248-3313
-----------------------------------------------------
Fax | 410-678-4878
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER, CREDENTIALING
-----------------------------------------------------
Name | TASHEDA BROUGHTON
-----------------------------------------------------
Credential | PESC
-----------------------------------------------------
Telephone | 252-248-3313
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------