=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063980449
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIC ZWARYCZ
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2018
-----------------------------------------------------
Last Update Date | 11/05/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4238 JAMES MADISON HWY
-----------------------------------------------------
City | FORK UNION
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-842-2916
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2111 WOODMAN OAKS LN
-----------------------------------------------------
City | POWHATAN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23139-7139
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 2306604716
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------