Healthcare Provider Details

I. General information

NPI: 1598861460
Provider Name (Legal Business Name): LAURA BETH LOOMIS PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 NORTH ST
BRISTOL VA
24201-3274
US

IV. Provider business mailing address

2311 KEYES LN
JOHNSON CITY TN
37601-2011
US

V. Phone/Fax

Practice location:
  • Phone: 276-669-4711
  • Fax: 276-669-0834
Mailing address:
  • Phone: 423-914-1095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2306602165
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: