Healthcare Provider Details

I. General information

NPI: 1821291964
Provider Name (Legal Business Name): LYMPHEDEMA PHYSIOTHERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 VIRGINIA BEACH BLVD
VIRGINIA BEACH VA
23452-1250
US

IV. Provider business mailing address

4128 CHESWICK LN
VIRGINIA BEACH VA
23455-6559
US

V. Phone/Fax

Practice location:
  • Phone: 757-615-2124
  • Fax:
Mailing address:
  • Phone: 757-615-2124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number0019 005511
License Number StateVA

VIII. Authorized Official

Name: DR. ZIA RAZZAQ
Title or Position: PRESIDENT
Credential: D.SC., LLCC, CMT
Phone: 757-615-2124