Healthcare Provider Details

I. General information

NPI: 1427068139
Provider Name (Legal Business Name): TIMOTHY WAYNE MCDANIEL P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 11/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

694 SHARON RD SUITE R
KING WILLIAM VA
23086-3640
US

IV. Provider business mailing address

694 SHARON RD SUITE R
KING WILLIAM VA
23086-3640
US

V. Phone/Fax

Practice location:
  • Phone: 804-769-7504
  • Fax: 804-769-7524
Mailing address:
  • Phone: 804-769-7504
  • Fax: 804-769-7524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305201811
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: