=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265810451
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DOMINION PHYSICAL THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2015
-----------------------------------------------------
Last Update Date | 05/08/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12713 CAMDEN PARK CT
-----------------------------------------------------
City | BRISTOW
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20136-1291
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-899-1732
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12713 CAMDEN PARK CT
-----------------------------------------------------
City | BRISTOW
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20136-1291
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LAURA BARRETT
-----------------------------------------------------
Credential | M.S.P.T.
-----------------------------------------------------
Telephone | 703-899-1732
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------