Provider Demographics
NPI:1386964773
Name:OPTIMAL PHYSICAL THERAPY GYM LLC
Entity type:Organization
Organization Name:OPTIMAL PHYSICAL THERAPY GYM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:RANDLE
Authorized Official - Last Name:COLES
Authorized Official - Suffix:JR
Authorized Official - Credentials:MPT
Authorized Official - Phone:267-475-2458
Mailing Address - Street 1:600 WASHINGTON AVE
Mailing Address - Street 2:SUITE 18U-A
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-4836
Mailing Address - Country:US
Mailing Address - Phone:215-678-4620
Mailing Address - Fax:215-701-2254
Practice Address - Street 1:600 WASHINGTON AVE
Practice Address - Street 2:SUITE 18U-A
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19147-4836
Practice Address - Country:US
Practice Address - Phone:215-678-4620
Practice Address - Fax:215-701-2254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-08
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT015725225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102601450-0001Medicaid
PA102601450-0001Medicaid