1265712103 NPI number — TIDEWATER PHYSICAL THERAPY, LLC

Table of content: (NPI 1265712103)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265712103 NPI number — TIDEWATER PHYSICAL THERAPY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TIDEWATER PHYSICAL THERAPY, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265712103
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/05/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
350 NEW FIDELITY CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GARNER
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27529-2665
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-258-2714
Provider Business Mailing Address Fax Number:
410-648-4878

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1580 ARMORY DR
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
FRANKLIN
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23851-2452
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-562-0990
Provider Business Practice Location Address Fax Number:
757-562-0496
Provider Enumeration Date:
08/23/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PEARSON
Authorized Official First Name:
PENNY
Authorized Official Middle Name:
Authorized Official Title or Position:
RCM DIRECTOR
Authorized Official Telephone Number:
443-225-4492

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)