Basic Information
Provider Information | |||||||||
NPI: | 1578196127 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PROFESSIONAL THERAPIES OF ROANOKE INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1110 SHAWNEE RD | ||||||||
Address2: |   | ||||||||
City: | LIMA | ||||||||
State: | OH | ||||||||
PostalCode: | 458053529 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4192216717 | ||||||||
FaxNumber: | 4192220507 | ||||||||
Practice Location | |||||||||
Address1: | 1380 AMERICAN WAY COURT | ||||||||
Address2: | UNIT C | ||||||||
City: | BEDFORD | ||||||||
State: | VA | ||||||||
PostalCode: | 24523 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4192216717 | ||||||||
FaxNumber: | 4192220507 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/21/2020 | ||||||||
LastUpdateDate: | 02/21/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ROUSH | ||||||||
AuthorizedOfficialFirstName: | BRAD | ||||||||
AuthorizedOfficialMiddleName: | C. | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 4192216712 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/21/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
No ID Information.