MEDICARE: LIFE FITNESS PHYSICAL THERAPY 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	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1285882670
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE FITNESS PHYSICAL THERAPY LLC

Provider Business Mailing Address
First Line	:	9171 BALTIMORE NATIONAL PIKE
Second Line	:	SUITE 120
City	:	ELLICOTT CITY
State	:	MD
Zip	:	21042-3944
Country	:	US
Telephone Number	:	410-480-3705
Fax Number	:	410-480-3707

Provider Business Practice Location Address
First Line	:	9171 BALTIMORE NATIONAL PIKE
Second Line	:	SUITE 120
City	:	ELLICOTT CITY
State	:	MD
Zip	:	21042-3944
Country	:	US
Telephone Number	:	410-480-3705
Fax Number	:	410-480-3707

Authorized Official
Title or Position	:	VP, AUTHORIZED OFFICIAL
Name	:	JANNA KING
Credential	:
Telephone Number	:	713-297-7000

Provider Enumeration Date	:	08/28/2008
Last Update Date	:	08/28/2008

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