Provider Demographics
NPI:1902331085
Name:BLUE ROOM PT INC.
Entity Type:Organization
Organization Name:BLUE ROOM PT INC.
Other - Org Name:BLUE ROOM PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CONRAD
Authorized Official - Middle Name:SULTAN
Authorized Official - Last Name:OSIPOWICZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-505-5544
Mailing Address - Street 1:13505 DULLES TECHNOLOGY DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20171-3401
Mailing Address - Country:US
Mailing Address - Phone:240-505-5544
Mailing Address - Fax:301-365-4203
Practice Address - Street 1:8530 AMANDA PL
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180-6873
Practice Address - Country:US
Practice Address - Phone:240-505-5544
Practice Address - Fax:301-365-4203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-26
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty