Healthcare Provider Details

I. General information

NPI: 1952363822
Provider Name (Legal Business Name): ATLANTIC SPORTS & REHABILITATION SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 07/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 INCARNATION DR SUITE 101
CHARLOTTESVILLE VA
22901-5708
US

IV. Provider business mailing address

1410 INCARNATION DR SUITE 101
CHARLOTTESVILLE VA
22901-5708
US

V. Phone/Fax

Practice location:
  • Phone: 434-978-4915
  • Fax: 434-978-7194
Mailing address:
  • Phone: 434-978-4915
  • Fax: 434-978-7194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2315014631
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number2305004631
License Number StateVA

VIII. Authorized Official

Name: MARK W TULENKO
Title or Position: DIRECTOR
Credential: MPT OCS
Phone: 434-978-4915