=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487144218
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAIN LINE PHYSIO, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2018
-----------------------------------------------------
Last Update Date | 05/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 PONT READING RD STE 200B
-----------------------------------------------------
City | ARDMORE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19003-1937
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-380-5185
-----------------------------------------------------
Fax | 844-823-5665
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 700 PONT READING RD STE 200B
-----------------------------------------------------
City | ARDMORE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19003-1937
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-380-5185
-----------------------------------------------------
Fax | 844-823-5665
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. CHRISTOPHER LEIB
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 484-380-5185
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | PT018221
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------