1235318403 NPI number — SHADY GROVE PHYSICAL THERAPY & REHAB CENTER, LLC

Table of content: (NPI 1235318403)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235318403 NPI number — SHADY GROVE PHYSICAL THERAPY & REHAB CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHADY GROVE PHYSICAL THERAPY & REHAB CENTER, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235318403
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/11/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8907 SHADY GROVE CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GAITHERSBURG
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20877-1308
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-921-9818
Provider Business Mailing Address Fax Number:
301-921-0719

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8907 SHADY GROVE CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GAITHERSBURG
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20877-1308
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-921-9818
Provider Business Practice Location Address Fax Number:
301-921-0719
Provider Enumeration Date:
10/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RAINA
Authorized Official First Name:
PRITI
Authorized Official Middle Name:
W
Authorized Official Title or Position:
PARTNER/PHYSICAL THERAPIST
Authorized Official Telephone Number:
301-921-9818

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  15535 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: G00742 . This is a "GROUP NPI" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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