Basic Information
| Provider Information | |||||||||
| NPI: | 1508410200 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | DEREK | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 CORPORATE DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352425424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178392125 | ||||||||
| FaxNumber: | 7175651104 | ||||||||
| Practice Location | |||||||||
| Address1: | 160 PEDRO WAY | ||||||||
| Address2: | |||||||||
| City: | WINCHESTER | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403918354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8597452152 | ||||||||
| FaxNumber: | 8597452153 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2019 | ||||||||
| LastUpdateDate: | 07/31/2019 | ||||||||
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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 | 225200000X | A02775 | KY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.