=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336890987
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFT PHYSICAL THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2022
-----------------------------------------------------
Last Update Date | 01/14/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10004 MONTGOMERY RD
-----------------------------------------------------
City | MONTGOMERY
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45242-5322
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-800-0848
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2247 STATE ROUTE 132
-----------------------------------------------------
City | GOSHEN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45122-9714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-652-9652
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ANDREA REED
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 513-652-9652
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------