Provider Demographics
NPI:1326827957
Name:MIND BODY SOUL PHYSICAL THERAPY
Entity Type:Organization
Organization Name:MIND BODY SOUL PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LEAD PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:PENQUE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:716-425-6625
Mailing Address - Street 1:836 BRIDGE ST APT 16
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01850-1610
Mailing Address - Country:US
Mailing Address - Phone:716-425-6625
Mailing Address - Fax:
Practice Address - Street 1:836 BRIDGE ST APT 16
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01850-1610
Practice Address - Country:US
Practice Address - Phone:716-425-6625
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy