Basic Information
Provider Information | |||||||||
NPI: | 1306225339 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | IVYREHAB SEPT, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
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Mailing Information | |||||||||
Address1: | 5301 PROVIDENCE RD | ||||||||
Address2: | SUITE 80 | ||||||||
City: | VIRGINIA BEACH | ||||||||
State: | VA | ||||||||
PostalCode: | 234644128 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7579324261 | ||||||||
FaxNumber: | 7574677900 | ||||||||
Practice Location | |||||||||
Address1: | 70 JEFFERSON COURT | ||||||||
Address2: | SUITE 102 | ||||||||
City: | ZION CROSSROADS | ||||||||
State: | VA | ||||||||
PostalCode: | 22942 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5408323061 | ||||||||
FaxNumber: | 5408323062 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/22/2015 | ||||||||
LastUpdateDate: | 11/20/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MILES | ||||||||
AuthorizedOfficialFirstName: | KENNETH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EVP & CFO | ||||||||
AuthorizedOfficialTelephone: | 6315805200 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   | 235Z00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   | 225100000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.