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General NPI Number Information
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NPI Number | 1659887396
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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 | 12/18/2017
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Last Update Date | 11/25/2024
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Provider Practice Location Address
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Address Line | 4214 FORTUNA CENTER PLZ
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City | DUMFRIES
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State | VA
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Zip | 22025-1515
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Country | US
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Telephone | 571-402-2028
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Fax | 571-888-8048
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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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