Provider Demographics
NPI:1154578524
Name:AGILE PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:AGILE PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:CATES
Authorized Official - Last Name:ALTAMIRANO
Authorized Official - Suffix:
Authorized Official - Credentials:PT MS CSCS
Authorized Official - Phone:205-969-7887
Mailing Address - Street 1:3125 BLUE LAKE DR
Mailing Address - Street 2:
Mailing Address - City:VESTAVIA
Mailing Address - State:AL
Mailing Address - Zip Code:35243-2333
Mailing Address - Country:US
Mailing Address - Phone:205-969-7887
Mailing Address - Fax:205-969-7886
Practice Address - Street 1:3125 BLUE LAKE DR
Practice Address - Street 2:
Practice Address - City:VESTAVIA
Practice Address - State:AL
Practice Address - Zip Code:35243-2333
Practice Address - Country:US
Practice Address - Phone:205-969-7887
Practice Address - Fax:205-969-7886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-27
Last Update Date:2024-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH3294261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL515-92499OtherBLUE CROSS BLUE SHIELD OF ALABAMA
AL1265654073OtherNPI - INDIVIDUAL
AL1265654073OtherNPI - INDIVIDUAL