Healthcare Provider Details

I. General information

NPI: 1366996761
Provider Name (Legal Business Name): INNERLINKS PHYSICAL THERAPY AND WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2016
Last Update Date: 08/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 EXECUTIVE PARK CT
GERMANTOWN MD
20874-2643
US

IV. Provider business mailing address

3 EXECUTIVE PARK CT
GERMANTOWN MD
20874-2643
US

V. Phone/Fax

Practice location:
  • Phone: 301-706-0688
  • Fax: 301-515-6039
Mailing address:
  • Phone: 301-706-0688
  • Fax: 301-515-6039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number16448
License Number StateMD

VIII. Authorized Official

Name: KEITH R DONOVAN
Title or Position: OWNER
Credential: PT
Phone: 301-706-0688