1427726108 NPI number — DIPLOMAT PHYSICAL THERAPY CLINIC LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427726108 NPI number — DIPLOMAT PHYSICAL THERAPY CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIPLOMAT PHYSICAL THERAPY CLINIC LLC
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:
1427726108
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/30/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4400 BRECKENRIDGE LN STE 300B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40218-4129
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-749-6411
Provider Business Mailing Address Fax Number:
502-749-6413

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4400 BRECKENRIDGE LN STE 300B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40218-4129
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-749-6411
Provider Business Practice Location Address Fax Number:
502-749-6413
Provider Enumeration Date:
08/30/2021

Additional Information

Authorized Official

Authorized Official Last Name:
NANKWENYA
Authorized Official First Name:
ANDREW
Authorized Official Middle Name:
MORRICE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
502-712-1749

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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