1578671681 NPI number — PHYSCIAL AND AQUATIC THERAPY, INC.

Table of content: (NPI 1578671681)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578671681 NPI number — PHYSCIAL AND AQUATIC THERAPY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSCIAL AND AQUATIC 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:
1578671681
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/06/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
54 W 3RD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILLIAMSON
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25661-3508
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
54 W 3RD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILLIAMSON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25661-3508
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-235-4300
Provider Business Practice Location Address Fax Number:
304-235-0176
Provider Enumeration Date:
08/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KAZALAS
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
CHRISTOPHER
Authorized Official Title or Position:
PHYSICAL THERAPIST/OWNER
Authorized Official Telephone Number:
304-235-4300

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)

  • Identifier: 001723120 . This is a "PIN #" identifier . This identifiers is of the category "OTHER".
  • Identifier: 001711463 . This is a "BLUE CROSS/BLUE SHIELD GP" identifier . This identifiers is of the category "OTHER".




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