Provider Demographics
NPI:1437778008
Name:THE LIFESTYLE ATHLETE PLC
Entity Type:Organization
Organization Name:THE LIFESTYLE ATHLETE PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BACZEWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:802-338-1406
Mailing Address - Street 1:175 KENNEDY DR APT 17
Mailing Address - Street 2:
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-6787
Mailing Address - Country:US
Mailing Address - Phone:802-338-1406
Mailing Address - Fax:
Practice Address - Street 1:1879 WILLISTON RD
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-6008
Practice Address - Country:US
Practice Address - Phone:802-338-1406
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-13
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty