Provider Demographics
NPI:1396433629
Name:PHYSIOLIFE 605 PLLC
Entity type:Organization
Organization Name:PHYSIOLIFE 605 PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TREVER
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, ATC
Authorized Official - Phone:605-767-1601
Mailing Address - Street 1:220 S CLIFF AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:SD
Mailing Address - Zip Code:57032-2485
Mailing Address - Country:US
Mailing Address - Phone:605-767-1601
Mailing Address - Fax:605-767-1607
Practice Address - Street 1:220 S CLIFF AVE STE 102
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:SD
Practice Address - Zip Code:57032-2485
Practice Address - Country:US
Practice Address - Phone:605-770-7331
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-25
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy