Basic Information
| Provider Information | |||||||||
| NPI: | 1831583574 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLOUD | ||||||||
| FirstName: | GEORGE | ||||||||
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| NameSuffix: | III | ||||||||
| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3040 99TH ST | ||||||||
| Address2: | |||||||||
| City: | HIGHLAND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463223345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084206387 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2701 CHESTNUT STATION CT | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402996395 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003351060 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2015 | ||||||||
| LastUpdateDate: | 03/19/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 160.005886 | IL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | 225200000X | 06004967A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.