Healthcare Provider Details

I. General information

NPI: 1831734920
Provider Name (Legal Business Name): ON TRACK REHABILITATION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2019
Last Update Date: 11/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3702 BRENBROOK DR
RANDALLSTOWN MD
21133-4116
US

IV. Provider business mailing address

3702 BRENBROOK DR
RANDALLSTOWN MD
21133-4116
US

V. Phone/Fax

Practice location:
  • Phone: 443-415-0004
  • Fax:
Mailing address:
  • Phone: 443-415-0004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ERIN LOGAN
Title or Position: BUSINESS OWNER
Credential: PT
Phone: 443-415-0004