Provider Demographics
NPI:1720432529
Name:MAC PHYSICAL THERAPY GROUP LLC
Entity Type:Organization
Organization Name:MAC PHYSICAL THERAPY GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:MACDANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:540-424-5537
Mailing Address - Street 1:14 PIDGEON HILL DR STE 400
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20165-6133
Mailing Address - Country:US
Mailing Address - Phone:703-430-2371
Mailing Address - Fax:703-430-1968
Practice Address - Street 1:14 PIDGEON HILL DR STE 400
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20165-6133
Practice Address - Country:US
Practice Address - Phone:703-430-2371
Practice Address - Fax:703-430-1968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-18
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305306771261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2305206771OtherLICENSE