Basic Information
| Provider Information | |||||||||
| NPI: | 1164055216 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PREMISE HEALTH OF VIRGINIA MEDICAL, P.C | ||||||||
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| OtherOrganizationName: | NAVY FEDERAL WELLNESS CENTER WINCHESTER PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5500 MARYLAND WAY STE 120 | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370274993 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 141 SECURITY DR BLDG 1 | ||||||||
| Address2: | |||||||||
| City: | WINCHESTER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 226024672 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8772228808 | ||||||||
| FaxNumber: | 5407221404 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2020 | ||||||||
| LastUpdateDate: | 08/15/2022 | ||||||||
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| AuthorizedOfficialLastName: | LEIZMAN | ||||||||
| AuthorizedOfficialFirstName: | JON | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2164799063 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 08/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.