=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851774475
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FELICE PHYSICAL THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2015
-----------------------------------------------------
Last Update Date | 01/07/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11270 PEPPER RD
-----------------------------------------------------
City | HUNT VALLEY
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21031-1202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-408-8341
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3190 LAWNDALE RD
-----------------------------------------------------
City | FINKSBURG
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21048-1565
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-408-8341
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JEROD M FELICE
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 315-408-8341
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 22634
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------