Healthcare Provider Details

I. General information

NPI: 1245411701
Provider Name (Legal Business Name): SOUTHERN WEST VIRGINIA PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2007
Last Update Date: 07/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6107 CRAWLEY CREEK RD.
CHAPMANVILLE WV
25508
US

IV. Provider business mailing address

PO BOX 1647
CHAPMANVILLE WV
25508-1647
US

V. Phone/Fax

Practice location:
  • Phone: 304-855-9500
  • Fax: 304-855-9525
Mailing address:
  • Phone: 304-855-9500
  • Fax: 304-855-9525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number002118
License Number StateWV

VIII. Authorized Official

Name: MR. PATRICK M ELLIS
Title or Position: PHYSICAL THERAPIST/ OWNER
Credential: MSPT
Phone: 304-855-9500