Provider Demographics
NPI:1417916016
Name:WALLACE & NILAN PHYSICAL THERAPY AND FITNESS, LLC
Entity Type:Organization
Organization Name:WALLACE & NILAN PHYSICAL THERAPY AND FITNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROSS
Authorized Official - Middle Name:
Authorized Official - Last Name:NILAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:215-233-9677
Mailing Address - Street 1:1600 BETHLEHEM PIKE
Mailing Address - Street 2:
Mailing Address - City:FLOURTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19031-2026
Mailing Address - Country:US
Mailing Address - Phone:215-233-9677
Mailing Address - Fax:215-233-9498
Practice Address - Street 1:1600 BETHLEHEM PIKE
Practice Address - Street 2:
Practice Address - City:FLOURTOWN
Practice Address - State:PA
Practice Address - Zip Code:19031-2026
Practice Address - Country:US
Practice Address - Phone:215-233-9677
Practice Address - Fax:215-233-9498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-22
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA045999Medicare PIN