Healthcare Provider Details

I. General information

NPI: 1750657664
Provider Name (Legal Business Name): PEDIATRIC PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2012
Last Update Date: 03/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RR 6 BOX 260-6E
FAIRMONT WV
26554-9396
US

IV. Provider business mailing address

PO BOX 88
COLFAX WV
26566-0088
US

V. Phone/Fax

Practice location:
  • Phone: 304-367-0750
  • Fax:
Mailing address:
  • Phone: 304-367-0750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number1046-0165
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number1046-0165
License Number StateWV

VIII. Authorized Official

Name: MS. NANCY E HICKMAN
Title or Position: PRESIDENT
Credential: PT
Phone: 304-366-8395