Healthcare Provider Details

I. General information

NPI: 1922419506
Provider Name (Legal Business Name): FOREVER FIT PHYSICAL THERAPY & WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2014
Last Update Date: 05/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 NATIONAL DR SUITE 100
BURTONSVILLE MD
20866-1141
US

IV. Provider business mailing address

PO BOX 356
BURTONSVILLE MD
20866-0356
US

V. Phone/Fax

Practice location:
  • Phone: 301-421-1125
  • Fax: 301-500-2175
Mailing address:
  • Phone: 301-421-1125
  • Fax: 301-500-2175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RYAN C FREDERIC
Title or Position: MEMBER
Credential:
Phone: 301-421-1125