Provider Demographics
NPI:1376967083
Name:MCKENZIE SPORTS THERAPY LLC
Entity Type:Organization
Organization Name:MCKENZIE SPORTS THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:MCKENZIE
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:267-332-8102
Mailing Address - Street 1:161 LEVERINGTON AVE STE 1004
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19127-2076
Mailing Address - Country:US
Mailing Address - Phone:267-332-8102
Mailing Address - Fax:877-313-1445
Practice Address - Street 1:161 LEVERINGTON AVE STE 1004
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19127-2076
Practice Address - Country:US
Practice Address - Phone:267-332-8102
Practice Address - Fax:877-313-1445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-17
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT0187912251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA396749Medicare PIN