Provider Demographics
NPI:1467796359
Name:NORTHERN EDGE PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:NORTHERN EDGE PHYSICAL THERAPY LLC
Other - Org Name:NORTHERN EDGE PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:POORBAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:PT, SCD
Authorized Official - Phone:907-631-4029
Mailing Address - Street 1:984 N MERIDIAN PL # A
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7215
Mailing Address - Country:US
Mailing Address - Phone:907-631-4029
Mailing Address - Fax:907-631-4128
Practice Address - Street 1:984 N MERIDIAN PL STE A
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7215
Practice Address - Country:US
Practice Address - Phone:907-631-4029
Practice Address - Fax:907-631-4128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-16
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1581261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1467796359Medicare PIN