Basic Information
Provider Information | |||||||||
NPI: | 1215380290 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CENTER FOR WORK RECOVERY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5982 | ||||||||
Address2: |   | ||||||||
City: | VIRGINIA BEACH | ||||||||
State: | VA | ||||||||
PostalCode: | 234710982 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7574816701 | ||||||||
FaxNumber: | 7574816175 | ||||||||
Practice Location | |||||||||
Address1: | 762 INDEPENDENCE BLVD | ||||||||
Address2: | SUITE # 772 | ||||||||
City: | VIRGINIA BEACH | ||||||||
State: | VA | ||||||||
PostalCode: | 234556200 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7574816701 | ||||||||
FaxNumber: | 7574816175 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/14/2016 | ||||||||
LastUpdateDate: | 07/14/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MAROON | ||||||||
AuthorizedOfficialFirstName: | ROBERT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
AuthorizedOfficialTelephone: | 7572859797 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.