Basic Information
| Provider Information | |||||||||
| NPI: | 1023536372 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DANIS | ||||||||
| FirstName: | IAN | ||||||||
| MiddleName: | CRAIG | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 383 CORBIN CENTER DR | ||||||||
| Address2: | |||||||||
| City: | CORBIN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407011895 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065262913 | ||||||||
| FaxNumber: | 6065262901 | ||||||||
| Practice Location | |||||||||
| Address1: | 4031 N DIXIE HWY STE 104 | ||||||||
| Address2: | |||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2709824776 | ||||||||
| FaxNumber: | 2709824778 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2017 | ||||||||
| LastUpdateDate: | 06/27/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 007263 | KY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 7100493930 | 05 | KY | MEDICAID |