Provider Demographics
NPI:1831479047
Name:DOUGLASS BREATH OF LIFE
Entity type:Organization
Organization Name:DOUGLASS BREATH OF LIFE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED RESPIRATORY THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:LYDELL
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGLASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-877-1114
Mailing Address - Street 1:3901 CONSHOHOCKEN AVENUE
Mailing Address - Street 2:#8308
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131
Mailing Address - Country:US
Mailing Address - Phone:215-877-1114
Mailing Address - Fax:215-877-1114
Practice Address - Street 1:3901 CONSHOHOCKEN AVE
Practice Address - Street 2:#8308
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-5430
Practice Address - Country:US
Practice Address - Phone:215-877-1114
Practice Address - Fax:215-877-1114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-18
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAYM006253L227800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes227800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedGroup - Single Specialty