Provider Demographics
NPI:1972658003
Name:OLYMPIC REHABILITATION AND AQUATIC CENTER
Entity Type:Organization
Organization Name:OLYMPIC REHABILITATION AND AQUATIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:UFBERG
Authorized Official - Suffix:
Authorized Official - Credentials:LPT
Authorized Official - Phone:215-671-8909
Mailing Address - Street 1:11040 RENNARD ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19116-2618
Mailing Address - Country:US
Mailing Address - Phone:215-671-8909
Mailing Address - Fax:215-671-0686
Practice Address - Street 1:11040 RENNARD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19116-2618
Practice Address - Country:US
Practice Address - Phone:215-671-8909
Practice Address - Fax:215-671-0686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT-002109-E174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty