=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124498464
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TOTAL BALANCE REHABILITATION LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2015
-----------------------------------------------------
Last Update Date | 09/29/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3696 CRIOLLO DR
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23453-2221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-615-2195
-----------------------------------------------------
Fax | 757-689-0206
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3696 CRIOLLO DR
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23453-2221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-615-2195
-----------------------------------------------------
Fax | 757-689-0206
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | DR. NEQUAI TERRY MCLENDON
-----------------------------------------------------
Credential | D.P.T.
-----------------------------------------------------
Telephone | 757-615-2195
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 0105006790
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------