Provider Demographics
NPI:1174936579
Name:ADVANTAGE LIFE PHYSICAL THERAPY
Entity type:Organization
Organization Name:ADVANTAGE LIFE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ARLETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:410-458-4557
Mailing Address - Street 1:104 CHURCH LN
Mailing Address - Street 2:
Mailing Address - City:PIKESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21208-3786
Mailing Address - Country:US
Mailing Address - Phone:410-484-6127
Mailing Address - Fax:
Practice Address - Street 1:104 CHURCH LN
Practice Address - Street 2:SUITE 126
Practice Address - City:PIKESVILLE
Practice Address - State:MD
Practice Address - Zip Code:21208-3786
Practice Address - Country:US
Practice Address - Phone:410-484-6127
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-04
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD20692225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty