Basic Information
| Provider Information | |||||||||
| NPI: | 1134264096 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANTAGE PHYSICAL THERAPY & SPORTS PERFORMANCE, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 54 FRANKLIN ST | ||||||||
| Address2: | VILLAGE SQUARE PLAZA | ||||||||
| City: | WEYERS CAVE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 244862340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5402348800 | ||||||||
| FaxNumber: | 5402348939 | ||||||||
| Practice Location | |||||||||
| Address1: | 54 FRANKLIN ST | ||||||||
| Address2: | VILLAGE SQUARE PLAZA | ||||||||
| City: | WEYERS CAVE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 244862340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5402348800 | ||||||||
| FaxNumber: | 5402348939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2007 | ||||||||
| LastUpdateDate: | 08/05/2010 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5404341200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | PT, DPT, OCS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 294391 | 01 | VA | ANTHEM | OTHER | 299393 | 01 | VA | ANTHEM OT | OTHER |