Provider Demographics
NPI:1801295043
Name:SOUTHERN INDIANA MYOFASCIAL RELEASE, LLC
Entity type:Organization
Organization Name:SOUTHERN INDIANA MYOFASCIAL RELEASE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:PARDY
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:812-788-1118
Mailing Address - Street 1:101 NW 1ST ST STE D
Mailing Address - Street 2:
Mailing Address - City:PAOLI
Mailing Address - State:IN
Mailing Address - Zip Code:47454-1369
Mailing Address - Country:US
Mailing Address - Phone:812-788-1118
Mailing Address - Fax:888-371-6163
Practice Address - Street 1:101 NW 1ST ST STE D
Practice Address - Street 2:
Practice Address - City:PAOLI
Practice Address - State:IN
Practice Address - Zip Code:47454-1369
Practice Address - Country:US
Practice Address - Phone:812-788-1118
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-13
Last Update Date:2019-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31005499A261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitationGroup - Single Specialty