MEDICARE: CAPSTONE PHYSICAL THERAPY & FITNESS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2000X	Physical Therapy Clinic/Center	PT012924	PA

General Provider Information

NPI Number	:	1891971818
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAPSTONE PHYSICAL THERAPY & FITNESS LLC

Provider Business Mailing Address
First Line	:	4000 GYPSY LN
Second Line	:	#310
City	:	PHILADELPHIA
State	:	PA
Zip	:	19129-5460
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11000 ROOSEVELT BLVD
Second Line	:	WORLD GYM FITNESS CENTER
City	:	PHILADELPHIA
State	:	PA
Zip	:	19116-3961
Country	:	US
Telephone Number	:	215-872-3595
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. MARK ALLEN DONATHAN
Credential	:	PT
Telephone Number	:	215-872-3595

Provider Enumeration Date	:	01/22/2008
Last Update Date	:	06/05/2008

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