MEDICARE: PERFORMANCE PHYSICAL THERAPY OF STAFFORD, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2251G0304X	Geriatric Physical Therapist	2305204166	VA
2	2251P0200X	Pediatric Physical Therapist	2305204166	VA
3	2251S0007X	Sports Physical Therapist	2305204166	VA
4	2251X0800X	Orthopedic Physical Therapist	2305204166	VA
5	225100000X	Physical Therapist	2305204166	VA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	VAA101671	OTHER	VA	MEDICARE PTAN

General Provider Information

NPI Number	:	1083928949
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PERFORMANCE PHYSICAL THERAPY OF STAFFORD, LLC

Provider Business Mailing Address
First Line	:	2777 JEFFERSON DAVIS HWY
Second Line	:	SUITE 109
City	:	STAFFORD
State	:	VA
Zip	:	22554-6219
Country	:	US
Telephone Number	:	540-318-8615
Fax Number	:	540-318-8619

Provider Business Practice Location Address
First Line	:	2777 JEFFERSON DAVIS HWY
Second Line	:	109
City	:	STAFFORD
State	:	VA
Zip	:	22554-8323
Country	:	US
Telephone Number	:	540-318-8615
Fax Number	:	540-318-8619

Authorized Official
Title or Position	:	OWNER
Name	:	DR. LATASHA R BLANTON
Credential	:	DPT
Telephone Number	:	540-327-1740

Provider Enumeration Date	:	08/03/2010
Last Update Date	:	09/17/2014

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Directions to “PERFORMANCE PHYSICAL THERAPY OF STAFFORD, LLC ” Practice Location

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