Provider Demographics
NPI:1881934453
Name:PEACOCK PHYSICAL THERAPY SERVICES LLC
Entity type:Organization
Organization Name:PEACOCK PHYSICAL THERAPY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JANINE
Authorized Official - Middle Name:
Authorized Official - Last Name:PEACOCK
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:240-718-8103
Mailing Address - Street 1:PO BOX 1066
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20604-1066
Mailing Address - Country:US
Mailing Address - Phone:240-718-8103
Mailing Address - Fax:443-729-0619
Practice Address - Street 1:11813 PARK WALDORF LN STE 522
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20601
Practice Address - Country:US
Practice Address - Phone:240-718-8103
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-19
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty