=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972915841
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VITALITY PHYSICAL THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2014
-----------------------------------------------------
Last Update Date | 12/16/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3510 RAYMOOR RD
-----------------------------------------------------
City | KENSINGTON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20895-3126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-505-3923
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3510 RAYMOOR RD
-----------------------------------------------------
City | KENSINGTON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20895-3126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-505-3923
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | RUCHI ACHARYA
-----------------------------------------------------
Credential | MSPT
-----------------------------------------------------
Telephone | 240-505-3923
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 022354
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------