Provider Demographics
NPI:1366854846
Name:MLG PHYSICAL THERAPY PLLC
Entity Type:Organization
Organization Name:MLG PHYSICAL THERAPY PLLC
Other - Org Name:ACTIVE PERFORMANCE PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:GALLEGOS
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:317-557-2334
Mailing Address - Street 1:PO BOX 455
Mailing Address - Street 2:
Mailing Address - City:CARROLL
Mailing Address - State:IA
Mailing Address - Zip Code:51401-0455
Mailing Address - Country:US
Mailing Address - Phone:712-393-7000
Mailing Address - Fax:712-393-7001
Practice Address - Street 1:1824 HIGHWAY 30 E
Practice Address - Street 2:
Practice Address - City:DENISON
Practice Address - State:IA
Practice Address - Zip Code:51442-2101
Practice Address - Country:US
Practice Address - Phone:712-393-7000
Practice Address - Fax:712-393-7001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-02
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy