MEDICARE: EZEPHYSICAL THERAPY 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	2305206212	VA

General Provider Information

NPI Number	:	1477047280
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EZEPHYSICAL THERAPY LLC

Provider Business Mailing Address
First Line	:	1311 BERNARD ST
Second Line	:
City	:	SOUTH BOSTON
State	:	VA
Zip	:	24592-2611
Country	:	US
Telephone Number	:	586-219-7872
Fax Number	:

Provider Business Practice Location Address
First Line	:	141 N MAIN ST
Second Line	:
City	:	CHASE CITY
State	:	VA
Zip	:	23924-1609
Country	:	US
Telephone Number	:	586-219-7872
Fax Number	:

Authorized Official
Title or Position	:	PHYSICAL THERAPIST
Name	:	MR. JAGDEEP SINGH
Credential	:	PT
Telephone Number	:	586-219-7872

Provider Enumeration Date	:	06/15/2018
Last Update Date	:	06/15/2018

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