MEDICARE: MR. SHAUN GOULBOURNE PHYSICAL THERAPIST

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	002839	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1538299540
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SHAUN GOULBOURNE PHYSICAL THERAPIST

Provider Business Mailing Address
First Line	:	PO BOX 911148
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40591-1148
Country	:	US
Telephone Number	:	859-278-2121
Fax Number	:	859-276-1649

Provider Business Practice Location Address
First Line	:	1485 S DIXIE ST
Second Line	:
City	:	HORSE CAVE
State	:	KY
Zip	:	42749-1457
Country	:	US
Telephone Number	:	270-786-4551
Fax Number	:	270-786-4551

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/07/2007
Last Update Date	:	07/08/2007

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