Provider Demographics
NPI:1679718191
Name:AQUAHAB, LP
Entity Type:Organization
Organization Name:AQUAHAB, LP
Other - Org Name:AQUAHAB PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:SIEDLECKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-677-0400
Mailing Address - Street 1:3600 GRANT AVE
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19114-2630
Mailing Address - Country:US
Mailing Address - Phone:215-677-0400
Mailing Address - Fax:215-671-1837
Practice Address - Street 1:3600 GRANT AVE
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19114-2630
Practice Address - Country:US
Practice Address - Phone:215-677-0400
Practice Address - Fax:215-671-1837
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-12
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN002660133NN1002X
PADN003739133NN1002X
PADN003889133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2864330000OtherINDEPENDENCE BLUE CROSS