Healthcare Provider Details

I. General information

NPI: 1912140112
Provider Name (Legal Business Name): PRESTIGE PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2009
Last Update Date: 04/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

186 THOMAS JOHNSON DR STE 105
FREDERICK MD
21702-4315
US

IV. Provider business mailing address

23202 BREWERS TAVERN WAY
CLARKSBURG MD
20871-4391
US

V. Phone/Fax

Practice location:
  • Phone: 301-829-6770
  • Fax: 301-829-6610
Mailing address:
  • Phone: 301-829-6770
  • Fax: 301-829-6610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number140233
License Number StateMD

VIII. Authorized Official

Name: MR. RICHARD E DIXON JR.
Title or Position: OWNER
Credential: PT
Phone: 301-829-6770