Healthcare Provider Details

I. General information

NPI: 1710527841
Provider Name (Legal Business Name): PROFESSIONAL THERAPIES OF ROANOKE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2020
Last Update Date: 01/07/2020
Certification Date: 01/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4017 COLLEGE AVE
BLUEFIELD VA
24605-2043
US

IV. Provider business mailing address

1110 SHAWNEE RD
LIMA OH
45805-3529
US

V. Phone/Fax

Practice location:
  • Phone: 419-221-6717
  • Fax: 419-222-0507
Mailing address:
  • Phone: 419-221-6717
  • Fax: 419-222-0507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. BRAD C. ROUSH
Title or Position: EXECUTIVE VICE PRESIDENT
Credential:
Phone: 419-221-6712