=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871212183
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOULRISE PHYSICAL THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2022
-----------------------------------------------------
Last Update Date | 11/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 912 KINGS HWY
-----------------------------------------------------
City | HADDON HEIGHTS
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08035-1218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-433-4008
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1907 DEPTFORD CENTER RD STE 3
-----------------------------------------------------
City | DEPTFORD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08096-5633
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-433-4008
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | ASHA PANDEY-SMITH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 856-433-4008
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------