Provider Demographics
NPI:1649284977
Name:EISENHOFER, JUSTIN D (DPT, OCS, CSCS)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:D
Last Name:EISENHOFER
Suffix:
Gender:M
Credentials:DPT, OCS, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 36TH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26101-1005
Mailing Address - Country:US
Mailing Address - Phone:304-917-3660
Mailing Address - Fax:304-917-3674
Practice Address - Street 1:5479 POTTSVILLE PIKE
Practice Address - Street 2:SUITE 200
Practice Address - City:LEESPORT
Practice Address - State:PA
Practice Address - Zip Code:19533-8650
Practice Address - Country:US
Practice Address - Phone:610-926-6778
Practice Address - Fax:610-926-7200
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV002261225100000X
PAPT019473225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2617663Medicaid
WV3810003931Medicaid
P00033898OtherRAILROAD MEDICARE
PA1022270250001Medicaid
PA140744ZB77Medicare PIN
WV3810003931Medicaid