Healthcare Provider Details

I. General information

NPI: 1821324070
Provider Name (Legal Business Name): ROTHEA KORNELIUS PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2009
Last Update Date: 10/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 N LUNENBURG AVE
SOUTH HILL VA
23970-1625
US

IV. Provider business mailing address

507 N LUNENBURG AVE
SOUTH HILL VA
23970-1625
US

V. Phone/Fax

Practice location:
  • Phone: 434-447-3527
  • Fax:
Mailing address:
  • Phone: 434-447-3527
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305203430
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: