MEDICARE: PENN NEUROMUSCULAR DIAGNOSTICS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2000X	Physical Therapy Clinic/Center

General Provider Information

NPI Number	:	1063761625
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PENN NEUROMUSCULAR DIAGNOSTICS, LLC

Provider Business Mailing Address
First Line	:	9 N 7TH ST
Second Line	:	2ND FLOOR, TOWNPLACE VICTORIA
City	:	INDIANA
State	:	PA
Zip	:	15701-1880
Country	:	US
Telephone Number	:	724-801-8894
Fax Number	:	724-465-6032

Provider Business Practice Location Address
First Line	:	1 BRADDOCK ROAD AVE
Second Line	:	SUITE C
City	:	MT PLEASANT
State	:	PA
Zip	:	15666-1458
Country	:	US
Telephone Number	:	724-801-8894
Fax Number	:	724-465-6032

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	THOMAS W ZAUCHA
Credential	:
Telephone Number	:	724-801-8894

Provider Enumeration Date	:	08/29/2012
Last Update Date	:	11/27/2012

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