Provider Demographics
NPI:1518231091
Name:LANGE, MARC ANTONIO (PT)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:ANTONIO
Last Name:LANGE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 JACKSON RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37072-3174
Mailing Address - Country:US
Mailing Address - Phone:407-803-3067
Mailing Address - Fax:502-213-4638
Practice Address - Street 1:1000 JACKSON RD
Practice Address - Street 2:SUITE 100
Practice Address - City:GOODLETTSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37072-3174
Practice Address - Country:US
Practice Address - Phone:407-803-3067
Practice Address - Fax:502-213-4638
Is Sole Proprietor?:No
Enumeration Date:2012-03-01
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT23485225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist