Basic Information
| Provider Information | |||||||||
| NPI: | 1568179083 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEREDITH | ||||||||
| FirstName: | WADE | ||||||||
| MiddleName: | AUSTEN | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 383 CORBIN CENTER DR | ||||||||
| Address2: | |||||||||
| City: | CORBIN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407011895 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065262911 | ||||||||
| FaxNumber: | 6065262901 | ||||||||
| Practice Location | |||||||||
| Address1: | 4031 N DIXIE HWY STE 104 | ||||||||
| Address2: | |||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427017874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2709824776 | ||||||||
| FaxNumber: | 2709824778 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2022 | ||||||||
| LastUpdateDate: | 11/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 008700 | KY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 008700 | 01 | KY | STATE LICENSE | OTHER |