Provider Demographics
NPI:1215185608
Name:LIFE FITNESS PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:LIFE FITNESS PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP, AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JANNA
Authorized Official - Middle Name:P
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-297-7000
Mailing Address - Street 1:3350 WILKENS AVE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229-4600
Mailing Address - Country:US
Mailing Address - Phone:410-368-1026
Mailing Address - Fax:410-368-1047
Practice Address - Street 1:3350 WILKENS AVE
Practice Address - Street 2:SUITE 303
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-4600
Practice Address - Country:US
Practice Address - Phone:410-368-1026
Practice Address - Fax:410-368-1047
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFE FITNESS PHYSICAL THERAPY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-28
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD008NMedicare PIN