Healthcare Provider Details

I. General information

NPI: 1093194193
Provider Name (Legal Business Name): IVYREHAB SEPT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2015
Last Update Date: 11/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 757-648-8562
  • Fax: 757-648-8564
Mailing address:
  • Phone: 757-932-4261
  • Fax: 757-467-7900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

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