Provider Demographics
NPI:1699549550
Name:GRIFFIN, IVERSON III
Entity type:Individual
Prefix:
First Name:IVERSON
Middle Name:
Last Name:GRIFFIN
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:374 KROGER WAY
Mailing Address - Street 2:
Mailing Address - City:VERSAILLES
Mailing Address - State:KY
Mailing Address - Zip Code:40383-1915
Mailing Address - Country:US
Mailing Address - Phone:859-286-6848
Mailing Address - Fax:
Practice Address - Street 1:374 KROGER WAY
Practice Address - Street 2:
Practice Address - City:VERSAILLES
Practice Address - State:KY
Practice Address - Zip Code:40383-1915
Practice Address - Country:US
Practice Address - Phone:859-286-6848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-10
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY008942225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist