Provider Demographics
NPI:1770027260
Name:SOUTHERN MARYLAND MYOFASCIAL RELEASE, INC.
Entity Type:Organization
Organization Name:SOUTHERN MARYLAND MYOFASCIAL RELEASE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:410-449-6682
Mailing Address - Street 1:12699 CHEYENNE TRL
Mailing Address - Street 2:
Mailing Address - City:LUSBY
Mailing Address - State:MD
Mailing Address - Zip Code:20657-4512
Mailing Address - Country:US
Mailing Address - Phone:410-449-6682
Mailing Address - Fax:410-449-6684
Practice Address - Street 1:90 HOLIDAY DRIVE
Practice Address - Street 2:SUITE C AND D1
Practice Address - City:SOLOMONS
Practice Address - State:MD
Practice Address - Zip Code:20688
Practice Address - Country:US
Practice Address - Phone:410-449-6682
Practice Address - Fax:410-449-6684
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-19
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD204142251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty