Provider Demographics
NPI:1669472999
Name:IXL REHAB & FITNESS CENTER LLC
Entity Type:Organization
Organization Name:IXL REHAB & FITNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:SHARR
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, CLT-LANA
Authorized Official - Phone:724-662-1776
Mailing Address - Street 1:139 NORTH ERIE STREET
Mailing Address - Street 2:
Mailing Address - City:MERCER
Mailing Address - State:PA
Mailing Address - Zip Code:16137-1204
Mailing Address - Country:US
Mailing Address - Phone:724-662-1776
Mailing Address - Fax:724-662-1858
Practice Address - Street 1:139 NORTH ERIE STREET
Practice Address - Street 2:
Practice Address - City:MERCER
Practice Address - State:PA
Practice Address - Zip Code:16137-1204
Practice Address - Country:US
Practice Address - Phone:724-662-1776
Practice Address - Fax:724-662-1858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-28
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT005706-L225100000X
PA4000007220332B00000X, 332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA10114998000001Medicaid
PA10114998000001Medicaid
PA6325930001Medicare NSC