Basic Information
| Provider Information | |||||||||
| NPI: | 1134134893 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIFE FITNESS PHYSICAL THERAPY OF TOWSON, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1205 YORK RD | ||||||||
| Address2: | STE 19 | ||||||||
| City: | LUTHERVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210936210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102969195 | ||||||||
| FaxNumber: | 4102969197 | ||||||||
| Practice Location | |||||||||
| Address1: | 1205 YORK RD | ||||||||
| Address2: | STE 19 | ||||||||
| City: | LUTHERVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210936210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102969195 | ||||||||
| FaxNumber: | 4102969197 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2006 | ||||||||
| LastUpdateDate: | 11/26/2007 | ||||||||
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| AuthorizedOfficialLastName: | WEISMAN | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | IRA | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4102969195 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.