Provider Demographics
NPI:1801945878
Name:BOUNCE BACK PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:BOUNCE BACK PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLATWORTHY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:410-730-8686
Mailing Address - Street 1:5999 HARPERS FARM RD
Mailing Address - Street 2:SUITE W100
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-3013
Mailing Address - Country:US
Mailing Address - Phone:410-730-8686
Mailing Address - Fax:410-730-4119
Practice Address - Street 1:5999 HARPERS FARM RD
Practice Address - Street 2:SUITE W100
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-3013
Practice Address - Country:US
Practice Address - Phone:410-730-8686
Practice Address - Fax:410-730-4119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD20214261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD435PMedicare PIN