Basic Information
| Provider Information | |||||||||
| NPI: | 1922396100 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIFEBRIDGE SPORTS MEDICINE & REHABILITATION LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1245 | ||||||||
| Address2: | |||||||||
| City: | INDIANA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 157015245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7244653496 | ||||||||
| FaxNumber: | 2154134682 | ||||||||
| Practice Location | |||||||||
| Address1: | 9712 BELAIR RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | NOTTINGHAM | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212361111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102567070 | ||||||||
| FaxNumber: | 4102567077 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2011 | ||||||||
| LastUpdateDate: | 04/25/2012 | ||||||||
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| AuthorizedOfficialLastName: | POOL | ||||||||
| AuthorizedOfficialFirstName: | JAYNE | ||||||||
| AuthorizedOfficialMiddleName: | FLECK | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF COMPLIANCE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6108844803 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
No ID Information.