Healthcare Provider Details

I. General information

NPI: 1588172993
Provider Name (Legal Business Name): TIDEWATER PHYSICAL THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2018
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 CONNOR DR
CHARLOTTESVILLE VA
22911-5604
US

IV. Provider business mailing address

350 NEW FIDELITY CT
GARNER NC
27529-2665
US

V. Phone/Fax

Practice location:
  • Phone: 434-218-1021
  • Fax: 434-212-1935
Mailing address:
  • Phone: 919-258-2714
  • Fax: 410-648-4878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateVA

VIII. Authorized Official

Name: TASHEDA BROUGHTON
Title or Position: MANAGER, CREDENTIALING
Credential: PESC
Phone: 252-248-3313