Healthcare Provider Details

I. General information

NPI: 1679522684
Provider Name (Legal Business Name): AMELIA WELLNESS AND REHABILITATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 01/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12882 PATRICK HENRY HWY
AMELIA VA
23002-3929
US

IV. Provider business mailing address

12882 PATRICK HENRY HWY
AMELIA VA
23002-3929
US

V. Phone/Fax

Practice location:
  • Phone: 804-561-1617
  • Fax: 804-561-5533
Mailing address:
  • Phone: 804-561-1617
  • Fax: 804-561-5533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305006053
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0119002329
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2202004731
License Number StateVA

VIII. Authorized Official

Name: MR. TYLER M MOORE
Title or Position: OWNER
Credential:
Phone: 804-561-1617