1295256170 NPI number — TIDEWATER PHYSICAL THERAPY LLC

Table of content: (NPI 1295256170)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295256170 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:
6
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:
1295256170
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/25/2024
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:
15757 WC MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIDLOTHIAN
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23113-7327
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-858-0220
Provider Business Practice Location Address Fax Number:
804-419-0127
Provider Enumeration Date:
06/30/2017

Additional Information

Authorized Official

Authorized Official Last Name:
BROUGHTON
Authorized Official First Name:
TASHEDA
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER, CREDENTIALING
Authorized Official Telephone Number:
252-248-3313

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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