Provider Demographics
NPI:1295798205
Name:THOMAS, JUSTIN LYLE (ATC)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:LYLE
Last Name:THOMAS
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3450 DIVISION ST
Mailing Address - Street 2:REAR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1429
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1801 WILSON AVE
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:PA
Practice Address - Zip Code:19007-4220
Practice Address - Country:US
Practice Address - Phone:215-550-1017
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer