Provider Demographics
NPI:1730317785
Name:LEVEL 11 PHYSICAL THERAPY
Entity Type:Organization
Organization Name:LEVEL 11 PHYSICAL THERAPY
Other - Org Name:LEVEL 11
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MGR PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTINGLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-420-2512
Mailing Address - Street 1:10483 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:HOLLY
Mailing Address - State:MI
Mailing Address - Zip Code:48442-9210
Mailing Address - Country:US
Mailing Address - Phone:810-771-7686
Mailing Address - Fax:810-771-7685
Practice Address - Street 1:10483 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:HOLLY
Practice Address - State:MI
Practice Address - Zip Code:48442-9210
Practice Address - Country:US
Practice Address - Phone:810-771-7686
Practice Address - Fax:810-771-7685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-29
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation