Healthcare Provider Details

I. General information

NPI: 1285394155
Provider Name (Legal Business Name): MGM PT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2021
Last Update Date: 12/20/2021
Certification Date: 12/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5941 SNIDER RD STE A
MASON OH
45040-6733
US

IV. Provider business mailing address

8509 TENNYSON CT
WEST CHESTER OH
45069-6435
US

V. Phone/Fax

Practice location:
  • Phone: 513-965-1516
  • Fax:
Mailing address:
  • Phone: 513-965-1516
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MARK MCAULIFFE
Title or Position: OWNER
Credential:
Phone: 513-965-1516