Provider Demographics
NPI:1255330908
Name:AQUAHAB, LP
Entity Type:Organization
Organization Name:AQUAHAB, LP
Other - Org Name:AQUAHAB PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:GORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-751-5177
Mailing Address - Street 1:3600 GRANT AVENUE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19114
Mailing Address - Country:US
Mailing Address - Phone:856-751-5177
Mailing Address - Fax:856-751-5489
Practice Address - Street 1:3600 GRANT AVE
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19114-2630
Practice Address - Country:US
Practice Address - Phone:215-677-0400
Practice Address - Fax:215-671-1837
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-15
Last Update Date:2017-06-19
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
PA396667AMedicare ID - Type UnspecifiedPHYSICAL THERAPY