Provider Demographics
NPI:1801873716
Name:SOUTHEASTERN KENTUCKY PHYSICAL THERAPY CLINIC INC
Entity type:Organization
Organization Name:SOUTHEASTERN KENTUCKY PHYSICAL THERAPY CLINIC INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:KIM
Authorized Official - Last Name:CHEARY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:606-528-0870
Mailing Address - Street 1:1480 18TH ST
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40701-2721
Mailing Address - Country:US
Mailing Address - Phone:606-528-0870
Mailing Address - Fax:606-528-3449
Practice Address - Street 1:1480 18TH ST
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-2721
Practice Address - Country:US
Practice Address - Phone:606-528-0870
Practice Address - Fax:606-528-3449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-30
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0D0000059454OtherANTHEM
KY0057Medicare ID - Type Unspecified