Provider Demographics
NPI:1053604348
Name:OPTIMUM WELLNESS PHYSICAL THERAPY LLC.
Entity type:Organization
Organization Name:OPTIMUM WELLNESS PHYSICAL THERAPY LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARSHA
Authorized Official - Middle Name:TRACELYN
Authorized Official - Last Name:COLON
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:301-452-2168
Mailing Address - Street 1:9625 SURVEYOR CT
Mailing Address - Street 2:STE 120
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-4422
Mailing Address - Country:US
Mailing Address - Phone:703-335-8275
Mailing Address - Fax:703-656-4727
Practice Address - Street 1:9625 SURVEYOR CT
Practice Address - Street 2:STE 200A
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-4422
Practice Address - Country:US
Practice Address - Phone:703-335-8275
Practice Address - Fax:703-656-4727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-19
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305204344225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty