Healthcare Provider Details

I. General information

NPI: 1659647014
Provider Name (Legal Business Name): REBOUND PHYSICAL THERAPY & SPORTS PERFORMANCE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2012
Last Update Date: 06/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 MAIN STREET
CHAPMANVILLE WV
25508
US

IV. Provider business mailing address

PO BOX 945
CHAPMANVILLE WV
25508-0945
US

V. Phone/Fax

Practice location:
  • Phone: 304-310-4721
  • Fax: 304-310-4723
Mailing address:
  • Phone: 304-310-4721
  • Fax: 304-310-4723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberPT002703
License Number StateWV

VIII. Authorized Official

Name: DEREK DALTON
Title or Position: OWNER
Credential: PT, DPT
Phone: 304-310-4721