1093934861 NPI number — SOUTHEASTERN PHYSICAL THERAPY, INC

Table of content: (NPI 1093934861)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093934861 NPI number — SOUTHEASTERN PHYSICAL THERAPY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEASTERN PHYSICAL THERAPY, INC
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:
1093934861
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/22/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5301 PROVIDENCE RD
Provider Second Line Business Mailing Address:
SUITE 80
Provider Business Mailing Address City Name:
VIRGINIA BEACH
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23464-4128
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
754-467-1900
Provider Business Mailing Address Fax Number:
757-467-7900

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
905 BATTLEFIELD BLVD N
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
CHESAPEAKE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23320-4875
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-410-3157
Provider Business Practice Location Address Fax Number:
757-410-3861
Provider Enumeration Date:
04/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HARTLINE
Authorized Official First Name:
JEFF
Authorized Official Middle Name:
LOWELL
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
757-467-1900

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 ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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