Healthcare Provider Details

I. General information

NPI: 1740407527
Provider Name (Legal Business Name): SOUTHEASTERN PHYSICAL THERAPY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 05/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CROFTON PL LAKE MONTICELLO
PALMYRA VA
22963-3300
US

IV. Provider business mailing address

5301 PROVIDENCE RD SUITE 80
VIRGINIA BEACH VA
23464-4128
US

V. Phone/Fax

Practice location:
  • Phone: 434-589-9588
  • Fax: 434-589-4096
Mailing address:
  • Phone: 757-467-1900
  • Fax: 757-467-7900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: JEFF LOWELL HARTLINE
Title or Position: PRESIDENT/OWNER
Credential: MPT
Phone: 757-467-1900