Healthcare Provider Details

I. General information

NPI: 1649284977
Provider Name (Legal Business Name): JUSTIN D EISENHOFER DPT, OCS, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2006
Last Update Date: 05/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5479 POTTSVILLE PIKE SUITE 200
LEESPORT PA
19533-8650
US

IV. Provider business mailing address

415 36TH ST SUITE 100
PARKERSBURG WV
26101-1005
US

V. Phone/Fax

Practice location:
  • Phone: 610-926-6778
  • Fax: 610-926-7200
Mailing address:
  • Phone: 304-917-3660
  • Fax: 304-917-3674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number002261
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT019473
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2617663
Identifier TypeMEDICAID
Identifier StateOH
Identifier Issuer
# 2
Identifier3810003931
Identifier TypeMEDICAID
Identifier StateWV
Identifier Issuer
# 3
IdentifierP00033898
Identifier TypeOTHER
Identifier State
Identifier IssuerRAILROAD MEDICARE
# 4
Identifier1022270250001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: