Provider Demographics
NPI:1821217563
Name:ADVANTAGE PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:ADVANTAGE PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:TARKIO
Authorized Official - Middle Name:
Authorized Official - Last Name:CHESTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-333-7848
Mailing Address - Street 1:1392 RAWLINGS ST
Mailing Address - Street 2:
Mailing Address - City:WSHNGTN CT HS
Mailing Address - State:OH
Mailing Address - Zip Code:43160-1985
Mailing Address - Country:US
Mailing Address - Phone:740-333-7848
Mailing Address - Fax:740-333-1212
Practice Address - Street 1:1392 RAWLINGS ST
Practice Address - Street 2:
Practice Address - City:WSHNGTN CT HS
Practice Address - State:OH
Practice Address - Zip Code:43160-1985
Practice Address - Country:US
Practice Address - Phone:740-333-7848
Practice Address - Fax:740-333-1212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
696307OtherACN GRP-UNITED HEALTHCARE
000000380490OtherANTHEM BC AND BS
OH2636839Medicaid
OH2636839Medicaid
OH=========-00OtherBUREAU OF WORKERS COMP