Healthcare Provider Details

I. General information

NPI: 1467796359
Provider Name (Legal Business Name): NORTHERN EDGE PHYSICAL THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2012
Last Update Date: 04/12/2022
Certification Date: 04/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

984 N MERIDIAN PL STE A
WASILLA AK
99654-7215
US

IV. Provider business mailing address

984 N MERIDIAN PL # A
WASILLA AK
99654-7215
US

V. Phone/Fax

Practice location:
  • Phone: 907-631-4029
  • Fax: 907-631-4128
Mailing address:
  • Phone: 907-631-4029
  • Fax: 907-631-4128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number1581
License Number StateAK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: KEITH POORBAUGH
Title or Position: OWNER/MANAGER
Credential: PT, SCD
Phone: 907-631-4029