Healthcare Provider Details

I. General information

NPI: 1215565957
Provider Name (Legal Business Name): RED CANYON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2020
Last Update Date: 06/26/2025
Certification Date: 06/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7402 YORK RD STE 104
TOWSON MD
21204-7519
US

IV. Provider business mailing address

21 CROSS ROADS DRIVE SUITE 330
QWINGS MILLS MD
21117
US

V. Phone/Fax

Practice location:
  • Phone: 410-716-0222
  • Fax:
Mailing address:
  • Phone:
  • 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 Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MATT ROSEWAG
Title or Position: OWNER
Credential:
Phone: 410-442-4059