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General NPI Number Information
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NPI Number | 1982125100
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Entity Type | Organization
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Legal Business Name | THERAPY 360, LLC
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Dates
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Enumeration Date | 06/28/2017
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Last Update Date | 06/28/2017
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Provider Practice Location Address
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Address Line | 716 LEVY AVE
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City | CHARLOTTESVILLE
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State | VA
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Zip | 22902-5730
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Country | US
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Telephone | 12022574854
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Fax | 800-923-4304
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Provider Business Mailing Address
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Address Line | 716 LEVY AVE
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City | CHARLOTTESVILLE
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State | VA
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Zip | 22902-5730
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Country | US
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Telephone | 12022574854
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Fax | 800-923-4304
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Authorized Official
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Title or Position | MANAGER
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Name | DR. GILES ALEXANDER JACKSON
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Credential | PH.D.
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Telephone | 202-257-4854
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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 | 2305004961
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License Number State | VA
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