MEDICARE: IVYREHAB SEPT, 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	208100000X	Physical Medicine & Rehabilitation Physician

General Provider Information

NPI Number	:	1790276178
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IVYREHAB SEPT, LLC

Provider Business Mailing Address
First Line	:	4668 PEMBROKE BLVD STE 115
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23455-6423
Country	:	US
Telephone Number	:	757-932-4261
Fax Number	:	757-579-8690

Provider Business Practice Location Address
First Line	:	3253 TAYLOR RD STE 200
Second Line	:
City	:	CHESAPEAKE
State	:	VA
Zip	:	23321-2452
Country	:	US
Telephone Number	:	757-881-1138
Fax Number	:

Authorized Official
Title or Position	:	EVP & CFO
Name	:	KENNETH MILES
Credential	:
Telephone Number	:	914-777-8700

Provider Enumeration Date	:	05/22/2018
Last Update Date	:	09/14/2018

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