Provider Demographics
NPI:1093378168
Name:PHYSIALIGN LLC
Entity Type:Organization
Organization Name:PHYSIALIGN LLC
Other - Org Name:PHYSIALIGN
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:AUTHORIZED AGENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:
Authorized Official - Last Name:WEDAM
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:802-318-0581
Mailing Address - Street 1:PO BOX 64823
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05406-4823
Mailing Address - Country:US
Mailing Address - Phone:802-318-0581
Mailing Address - Fax:802-448-5951
Practice Address - Street 1:1233 SHELBURNE RD STE 190
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-7733
Practice Address - Country:US
Practice Address - Phone:802-318-0581
Practice Address - Fax:802-448-5951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-15
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatricsGroup - Multi-Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT040.0066530OtherVT LICENCE NUMBER