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General NPI Number Information
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NPI Number | 1396433629
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Entity Type | Organization
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Legal Business Name | PHYSIOLIFE 605 PLLC
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Dates
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Enumeration Date | 04/25/2023
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Last Update Date | 08/22/2023
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Provider Practice Location Address
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Address Line | 220 S CLIFF AVE STE 102
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City | HARRISBURG
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State | SD
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Zip | 57032-2485
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Country | US
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Telephone | 605-770-7331
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Fax |
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Provider Business Mailing Address
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Address Line | 220 S CLIFF AVE STE 102
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City | HARRISBURG
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State | SD
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Zip | 57032-2485
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Country | US
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Telephone | 605-767-1601
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Fax | 605-767-1607
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Authorized Official
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Title or Position | OWNER
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Name | TREVER WAGNER
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Credential | PT, DPT, ATC
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Telephone | 605-767-1601
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number |
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License Number State |
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