Provider Demographics
NPI:1316510282
Name:SOURCE PHYSIOTHERAPY LLC
Entity type:Organization
Organization Name:SOURCE PHYSIOTHERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSIOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:EMMANNOUIL
Authorized Official - Middle Name:
Authorized Official - Last Name:LAGOGIANNIS
Authorized Official - Suffix:
Authorized Official - Credentials:PT, MSC
Authorized Official - Phone:443-355-8891
Mailing Address - Street 1:14 HILLSYDE CT
Mailing Address - Street 2:
Mailing Address - City:COCKEYSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21030-1750
Mailing Address - Country:US
Mailing Address - Phone:443-355-8891
Mailing Address - Fax:
Practice Address - Street 1:10155 YORK RD STE 205-206
Practice Address - Street 2:
Practice Address - City:COCKEYSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21030-3352
Practice Address - Country:US
Practice Address - Phone:443-355-8891
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-20
Last Update Date:2024-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy