Basic Information
| Provider Information | |||||||||
| NPI: | 1962559476 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIFE FITNESS PHYSICAL THERAPY OF ELLICOTT CITY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9171 BALTIMORE NATIONAL PIKE | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | ELLICOTT CITY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210423922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104803705 | ||||||||
| FaxNumber: | 4104803707 | ||||||||
| Practice Location | |||||||||
| Address1: | 9171 BALTIMORE NATIONAL PIKE | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | ELLICOTT CITY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210423922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104803705 | ||||||||
| FaxNumber: | 4104803707 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2007 | ||||||||
| LastUpdateDate: | 10/02/2008 | ||||||||
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| AuthorizedOfficialLastName: | KING | ||||||||
| AuthorizedOfficialFirstName: | JANNA | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP, AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 7132977000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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.