Healthcare Provider Details

I. General information

NPI: 1326539719
Provider Name (Legal Business Name): IVYREHAB SEPT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2018
Last Update Date: 09/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12610 PATRICK HENRY DR STE H
NEWPORT NEWS VA
23602-9538
US

IV. Provider business mailing address

4668 PEMBROKE BLVD STE 115
VIRGINIA BEACH VA
23455-6423
US

V. Phone/Fax

Practice location:
  • Phone: 757-874-1470
  • Fax: 757-874-1472
Mailing address:
  • Phone: 757-932-4261
  • Fax: 757-579-8690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: KENNETH MILES
Title or Position: EVP & CFO
Credential:
Phone: 914-777-8700