=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124584453
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOMMY CARE PT, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2019
-----------------------------------------------------
Last Update Date | 09/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3619 MARDEAN DR
-----------------------------------------------------
City | CHESAPEAKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23321-4475
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-553-6701
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3619 MARDEAN DR
-----------------------------------------------------
City | CHESAPEAKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23321-4475
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-553-6701
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, PT
-----------------------------------------------------
Name | ERIN M. GLACE
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 757-553-6701
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------