Provider Demographics
NPI:1235318403
Name:SHADY GROVE PHYSICAL THERAPY & REHAB CENTER, LLC
Entity Type:Organization
Organization Name:SHADY GROVE PHYSICAL THERAPY & REHAB CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:PRITI
Authorized Official - Middle Name:W
Authorized Official - Last Name:RAINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-921-9818
Mailing Address - Street 1:8907 SHADY GROVE CT
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20877-1308
Mailing Address - Country:US
Mailing Address - Phone:301-921-9818
Mailing Address - Fax:301-921-0719
Practice Address - Street 1:8907 SHADY GROVE CT
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-1308
Practice Address - Country:US
Practice Address - Phone:301-921-9818
Practice Address - Fax:301-921-0719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-24
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15535174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG00742OtherGROUP NPI