1669463170 NPI number — PROFESSIONAL REHABILITATION ASSOCIATES, PSC

Table of content: (NPI 1669463170)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669463170 NPI number — PROFESSIONAL REHABILITATION ASSOCIATES, PSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL REHABILITATION ASSOCIATES, PSC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669463170
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5027 ATWOOD DR STE 2B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHMOND
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40475-8322
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-625-0001
Provider Business Mailing Address Fax Number:
895-625-1109

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5027 ATWOOD DR STE 2B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RICHMOND
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40475-8322
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-625-0001
Provider Business Practice Location Address Fax Number:
895-625-1109
Provider Enumeration Date:
11/03/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BROOKS
Authorized Official First Name:
MARK
Authorized Official Middle Name:
E
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
859-625-0001

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2251E1300X , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000190632 . This is a "BC/BS P-EMG" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 47015 . This is a "NGS PARIS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000215122 . This is a "BC/BS SPTA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000310944 . This is a "BC/BS RPTA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000060027 . This is a "BC/BS LPTA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 42858 . This is a "NSG RPTA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 4378 . This is a "NGS LPTA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000333709 . This is a "BC/BS HPTA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 87900312 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000199364 . This is a "BC/BS PARIS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 11128 . This is a "NGS HPTA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 47016 . This is a "NSG SPTA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: DB9812 . This is a "RAILROAD MCR" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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