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General NPI Number Information
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NPI Number | 1497244800
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Entity Type | Organization
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Legal Business Name | TIDEWATER PHYSICAL THERAPY LLC
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Dates
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Enumeration Date | 05/02/2018
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Last Update Date | 11/25/2024
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Provider Practice Location Address
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Address Line | 5629 PLANK RD STE 107
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City | FREDERICKSBURG
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State | VA
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Zip | 22407-7216
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Country | US
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Telephone | 540-445-0206
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Fax | 540-739-7473
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Provider Business Mailing Address
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Address Line | 2122 YORK RD STE 300
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City | OAK BROOK
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State | IL
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Zip | 60523-1925
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Country | US
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Telephone | 252-248-3313
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Fax | 410-648-4878
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Authorized Official
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Title or Position | MANAGER, CREDENTIALING
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Name | TASHEDA BROUGHTON
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Credential | PESC
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Telephone | 252-248-3313
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number |
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License Number State | VA
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