Healthcare Provider Details

I. General information

NPI: 1013054782
Provider Name (Legal Business Name): CRIPPLED CHILDREN'S HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10124 W BROAD ST STE K CHILDREN'S HOSPITAL THERAPY CENTER
GLEN ALLEN VA
23060-3330
US

IV. Provider business mailing address

2924 BROOK RD CREDENTIALING DEPT
RICHMOND VA
23220-1215
US

V. Phone/Fax

Practice location:
  • Phone: 804-273-6656
  • Fax: 804-273-6612
Mailing address:
  • Phone: 804-321-7474
  • Fax: 804-321-2728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberH1842
License Number StateVA

VIII. Authorized Official

Name: MR. SAMUEL G WEIDMAN
Title or Position: VICE PRESIDENT & CFO
Credential:
Phone: 804-321-7474