Provider Demographics
NPI:1679082820
Name:MILE-LEVEL PHYSICAL THERAPY
Entity type:Organization
Organization Name:MILE-LEVEL PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:GENTRY
Authorized Official - Suffix:
Authorized Official - Credentials:PT, MTC
Authorized Official - Phone:814-623-9022
Mailing Address - Street 1:7799 WOODBURY PIKE
Mailing Address - Street 2:
Mailing Address - City:ROARING SPRING
Mailing Address - State:PA
Mailing Address - Zip Code:16673-1141
Mailing Address - Country:US
Mailing Address - Phone:814-729-7021
Mailing Address - Fax:814-729-7068
Practice Address - Street 1:7799 WOODBURY PIKE
Practice Address - Street 2:
Practice Address - City:ROARING SPRING
Practice Address - State:PA
Practice Address - Zip Code:16673-1141
Practice Address - Country:US
Practice Address - Phone:814-729-7021
Practice Address - Fax:814-729-7068
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MILE-LEVEL PHYSICAL THERAPY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-09-20
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1009733210001Medicaid