MEDICARE: SOUTHEASTERN KENTUCKY PHYSICAL THERAPY CLINIC INC

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	261QP2000X	Physical Therapy Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0D0000059454	OTHER		ANTHEM

General Provider Information

NPI Number	:	1801873716
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHEASTERN KENTUCKY PHYSICAL THERAPY CLINIC INC

Provider Business Mailing Address
First Line	:	1480 18TH ST
Second Line	:
City	:	CORBIN
State	:	KY
Zip	:	40701-2721
Country	:	US
Telephone Number	:	606-528-0870
Fax Number	:	606-528-3449

Provider Business Practice Location Address
First Line	:	1480 18TH ST
Second Line	:
City	:	CORBIN
State	:	KY
Zip	:	40701-2721
Country	:	US
Telephone Number	:	606-528-0870
Fax Number	:	606-528-3449

Authorized Official
Title or Position	:	OWNER
Name	:	MR. WALTER KIM CHEARY
Credential	:	PT
Telephone Number	:	606-528-0870

Provider Enumeration Date	:	12/30/2005
Last Update Date	:	12/04/2013

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