MEDICARE: GRACE PHYSICAL THERAPY, PC

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	2251X0800X	Orthopedic Physical Therapist	2305004860	VA

General Provider Information

NPI Number	:	1154502763
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACE PHYSICAL THERAPY, PC

Provider Business Mailing Address
First Line	:	2201 CHARLES ST
Second Line	:	SUITE 105
City	:	FREDERICKSBURG
State	:	VA
Zip	:	22401-3378
Country	:	US
Telephone Number	:	540-899-6863
Fax Number	:

Provider Business Practice Location Address
First Line	:	2201 CHARLES ST
Second Line	:	SUITE 105
City	:	FREDERICKSBURG
State	:	VA
Zip	:	22401-3378
Country	:	US
Telephone Number	:	540-899-6863
Fax Number	:

Authorized Official
Title or Position	:	OWNER/DIRECTOR
Name	:	MR. CARL FRANCIS BRUNO
Credential	:	PT
Telephone Number	:	540-899-6863

Provider Enumeration Date	:	11/26/2007
Last Update Date	:	12/01/2009

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