Healthcare Provider Details

I. General information

NPI: 1073613238
Provider Name (Legal Business Name): WINCHESTER PHYSICAL THERAPY & SPORTS MEDICINE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 03/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 S REYMANN ST
RANSON WV
25438-1730
US

IV. Provider business mailing address

112 S REYMANN ST
RANSON WV
25438-1730
US

V. Phone/Fax

Practice location:
  • Phone: 304-725-3632
  • Fax: 304-725-8252
Mailing address:
  • Phone: 304-725-3632
  • Fax: 304-725-8252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number00269
License Number StateWV

VIII. Authorized Official

Name: GREGORY T HUMPHREYS
Title or Position: PRESIDENT
Credential: P.T.
Phone: 304-725-3632