Provider Demographics
NPI:1912140112
Name:PRESTIGE PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:PRESTIGE PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:E
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:JR
Authorized Official - Credentials:PT
Authorized Official - Phone:301-829-6770
Mailing Address - Street 1:23202 BREWERS TAVERN WAY
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20871-4391
Mailing Address - Country:US
Mailing Address - Phone:301-829-6770
Mailing Address - Fax:301-829-6610
Practice Address - Street 1:186 THOMAS JOHNSON DR STE 105
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4315
Practice Address - Country:US
Practice Address - Phone:301-829-6770
Practice Address - Fax:301-829-6610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-17
Last Update Date:2009-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD140233261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy