Provider Demographics
NPI:1629334644
Name:MARYLAND PHYSICAL THERAPY AND WELLNESS CENTER
Entity Type:Organization
Organization Name:MARYLAND PHYSICAL THERAPY AND WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARINA
Authorized Official - Middle Name:
Authorized Official - Last Name:KACHURINER
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:410-913-5933
Mailing Address - Street 1:4982 DORSEY HALL DR
Mailing Address - Street 2:UNIT C5
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-7775
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7350 VAN DUSEN RD
Practice Address - Street 2:SUITE 110
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-5263
Practice Address - Country:US
Practice Address - Phone:410-913-5933
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-03
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD20615225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty