Basic Information
| Provider Information | |||||||||
| NPI: | 1972765386 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROREHAB OF KENTUCKY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5629 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477165629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124760409 | ||||||||
| FaxNumber: | 8124761016 | ||||||||
| Practice Location | |||||||||
| Address1: | 702 BARRETT BLVD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | HENDERSON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 424204931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706314100 | ||||||||
| FaxNumber: | 2706314101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2008 | ||||||||
| LastUpdateDate: | 05/05/2017 | ||||||||
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| AuthorizedOfficialLastName: | WEMPE | ||||||||
| AuthorizedOfficialFirstName: | PATRICK | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8124760409 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 261QP2000X | 101107 | KY | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | 000000590926 | 01 | KY | BLUE CROSS BLUE SHIELD | OTHER |