=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407565070
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAPABLE TABLE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2022
-----------------------------------------------------
Last Update Date | 11/22/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 245 S SAINT BERNARD ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19139-4239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-378-3140
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 245 S SAINT BERNARD ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19139-4239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-378-3140
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | MINDY KING
-----------------------------------------------------
Credential | OTR/L
-----------------------------------------------------
Telephone | 412-378-3140
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------