1790270973 NPI number — TIDEWATER 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 1790270973 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:
1790270973
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:
2122 YORK RD STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAK BROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60523-1925
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-248-3313
Provider Business Mailing Address Fax Number:
410-648-4878

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
392 GARRISONVILLE RD STE 208
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STAFFORD
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22554-1576
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-602-4277
Provider Business Practice Location Address Fax Number:
540-628-8581
Provider Enumeration Date:
06/29/2018

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 , 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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