Provider Demographics
NPI:1588721005
Name:ANGOLA PHYSICAL THERAPY, INC.
Entity type:Organization
Organization Name:ANGOLA PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:ANZELMO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:260-668-7752
Mailing Address - Street 1:3270 INTERTECH DRIVE
Mailing Address - Street 2:
Mailing Address - City:ANGOLA
Mailing Address - State:IN
Mailing Address - Zip Code:46703-9337
Mailing Address - Country:US
Mailing Address - Phone:260-668-7752
Mailing Address - Fax:260-668-7552
Practice Address - Street 1:3270 INTERTECH DRIVE
Practice Address - Street 2:
Practice Address - City:ANGOLA
Practice Address - State:IN
Practice Address - Zip Code:46703-9337
Practice Address - Country:US
Practice Address - Phone:260-668-7752
Practice Address - Fax:260-668-7552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05003680A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN148780Medicare ID - Type Unspecified