1558564526 NPI number — CENTREVILLE PHYSICAL THERAPY, PC

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 1558564526 NPI number — CENTREVILLE PHYSICAL THERAPY, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTREVILLE PHYSICAL THERAPY, PC
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:
1558564526
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/24/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14631 LEE HWY
Provider Second Line Business Mailing Address:
SUITE 310
Provider Business Mailing Address City Name:
CENTREVILLE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20121-2112
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-222-5903
Provider Business Mailing Address Fax Number:
703-222-3765

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14631 LEE HWY
Provider Second Line Business Practice Location Address:
SUITE 310
Provider Business Practice Location Address City Name:
CENTREVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20121-2112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-222-5903
Provider Business Practice Location Address Fax Number:
703-222-3765
Provider Enumeration Date:
06/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GRYSKI
Authorized Official First Name:
JOANNE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
703-222-5903

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ANTHEM . This is a "196835" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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