Healthcare Provider Details

I. General information

NPI: 1164055216
Provider Name (Legal Business Name): PREMISE HEALTH OF VIRGINIA MEDICAL, P.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2020
Last Update Date: 08/15/2022
Certification Date: 08/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 SECURITY DR BLDG 1
WINCHESTER VA
22602-4672
US

IV. Provider business mailing address

5500 MARYLAND WAY STE 120
BRENTWOOD TN
37027-4993
US

V. Phone/Fax

Practice location:
  • Phone: 877-222-8808
  • Fax: 540-722-1404
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JON LEIZMAN
Title or Position: PRESIDENT
Credential: MD
Phone: 216-479-9063