Basic Information
Provider Information | |||||||||
NPI: | 1003142787 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TWIN COUNTY REGIONAL HOSPITAL OCCUPATIONAL THERAPY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | OUTPATIENT REHABILITATION SERVICES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 200 HOSPITAL DR | ||||||||
Address2: |   | ||||||||
City: | GALAX | ||||||||
State: | VA | ||||||||
PostalCode: | 243332227 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2762361675 | ||||||||
FaxNumber: | 2762363399 | ||||||||
Practice Location | |||||||||
Address1: | 607 GLENDALE RD | ||||||||
Address2: |   | ||||||||
City: | GALAX | ||||||||
State: | VA | ||||||||
PostalCode: | 243332209 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2762361675 | ||||||||
FaxNumber: | 2762363399 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/30/2009 | ||||||||
LastUpdateDate: | 10/30/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MONTGOMERY | ||||||||
AuthorizedOfficialFirstName: | NELSON | ||||||||
AuthorizedOfficialMiddleName: | LEE | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 2762361620 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CPA | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X |   | VA | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 007694 | 01 | VA | BLUE CROSS | OTHER | 0490115 | 05 | VA |   | MEDICAID |