=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972215044
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REFORM PHYSICAL THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2022
-----------------------------------------------------
Last Update Date | 04/12/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 496 N MAIN ST
-----------------------------------------------------
City | MINSTER
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45865-9537
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-628-2718
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 496 N MAIN ST
-----------------------------------------------------
City | MINSTER
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45865-9537
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-628-2718
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST
-----------------------------------------------------
Name | DR. PAIGE GILLIS
-----------------------------------------------------
Credential | PT, DPT
-----------------------------------------------------
Telephone | 419-953-4989
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------