Basic Information
| Provider Information | |||||||||
| NPI: | 1598895583 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HINES | ||||||||
| FirstName: | MELANIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | FROST | ||||||||
| OtherFirstName: | MELANIE | ||||||||
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| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 332 EZRA WALLS RD | ||||||||
| Address2: | |||||||||
| City: | LIBERTY | ||||||||
| State: | KY | ||||||||
| PostalCode: | 425397842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065262919 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 383 CORBIN CENTER DRIVE | ||||||||
| Address2: | |||||||||
| City: | CORBIN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065262919 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 002434 | KY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 87024345 | 05 | KY | MEDICAID |