Healthcare Provider Details

I. General information

NPI: 1457389595
Provider Name (Legal Business Name): TIDEWATER PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10128 W BROAD ST BLDG III
GLEN ALLEN VA
23060-6761
US

IV. Provider business mailing address

2122 YORK RD STE 300
OAK BROOK IL
60523-1925
US

V. Phone/Fax

Practice location:
  • Phone: 804-217-9210
  • Fax: 804-217-9213
Mailing address:
  • Phone: 252-248-3313
  • Fax: 410-648-4878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

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