Healthcare Provider Details

I. General information

NPI: 1164458329
Provider Name (Legal Business Name): SMR BANYAN TREE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 11/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5130 BRADENTON AVE SUITE B
DUBLIN OH
43017-7068
US

IV. Provider business mailing address

4714 GETTYSBURG RD LEGAL DEPT
MECHANICSBURG PA
17055-4325
US

V. Phone/Fax

Practice location:
  • Phone: 614-336-8733
  • Fax: 614-336-0658
Mailing address:
  • Phone: 717-972-1100
  • 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: MR. MICHAEL E TARVIN
Title or Position: VICE PRESIDENT & SECRETARY
Credential:
Phone: 717-972-1100