MEDICARE: TOTAL BALANCE REHABILITATION 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	225100000X	Physical Therapist	0105006790	VA

General Provider Information

NPI Number	:	1124498464
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TOTAL BALANCE REHABILITATION LLC

Provider Business Mailing Address
First Line	:	3696 CRIOLLO DR
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23453-2221
Country	:	US
Telephone Number	:	757-615-2195
Fax Number	:	757-689-0206

Provider Business Practice Location Address
First Line	:	3696 CRIOLLO DR
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23453-2221
Country	:	US
Telephone Number	:	757-615-2195
Fax Number	:	757-689-0206

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	DR. NEQUAI TERRY MCLENDON
Credential	:	D.P.T.
Telephone Number	:	757-615-2195

Provider Enumeration Date	:	09/29/2015
Last Update Date	:	09/29/2015

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