Provider Demographics
NPI:1831905934
Name:ON YOUR MARK PEDIATRIC PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:ON YOUR MARK PEDIATRIC PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:MARK
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:336-978-1145
Mailing Address - Street 1:230 ASHBOURNE LAKE CT
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-7905
Mailing Address - Country:US
Mailing Address - Phone:336-978-1145
Mailing Address - Fax:
Practice Address - Street 1:1016 BURKE ST
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-2413
Practice Address - Country:US
Practice Address - Phone:336-978-1145
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-04
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty