Provider Demographics
NPI:1578017901
Name:CONCIERGE PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:CONCIERGE PHYSICAL THERAPY, LLC
Other - Org Name:CONCIERGE PHYSICAL THERAPY& WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:OLUWATITOYIN
Authorized Official - Middle Name:
Authorized Official - Last Name:OGUNSOLA-SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:813-453-9896
Mailing Address - Street 1:1445 S BEULAH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-5725
Mailing Address - Country:US
Mailing Address - Phone:813-453-9896
Mailing Address - Fax:
Practice Address - Street 1:1445 S BEULAH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19147-5725
Practice Address - Country:US
Practice Address - Phone:813-453-9896
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-15
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA6372805225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty