1114256534 NPI number — GRACE PHYSICAL THERAPY, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114256534 NPI number — GRACE PHYSICAL THERAPY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRACE 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:
1114256534
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/14/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2201 CHARLES ST
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
FREDERICKSBURG
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22401-3378
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-899-6863
Provider Business Mailing Address Fax Number:
540-899-6865

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2201 CHARLES ST
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
FREDERICKSBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22401-3378
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-899-6863
Provider Business Practice Location Address Fax Number:
540-899-6865
Provider Enumeration Date:
12/14/2009

Additional Information

Authorized Official

Authorized Official Last Name:
BRUNO
Authorized Official First Name:
CARL
Authorized Official Middle Name:
FRANCIS
Authorized Official Title or Position:
OWNER/DIRECTOR
Authorized Official Telephone Number:
540-899-6863

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  2305004860 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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