=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528189016
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUMNER FITNESS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2007
-----------------------------------------------------
Last Update Date | 01/23/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4611 SANGAMORE RD STE K
-----------------------------------------------------
City | BETHESDA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20816-2547
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-229-9110
-----------------------------------------------------
Fax | 301-229-9465
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4611 SANGAMORE RD STE K
-----------------------------------------------------
City | BETHESDA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20816-2547
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-229-9110
-----------------------------------------------------
Fax | 301-229-9465
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. MICHAEL O'FLAHAVAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 301-229-9110
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 21065
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------