Basic Information
| Provider Information | |||||||||
| NPI: | 1669627048 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TIDEWATER PHYSICAL THERAPY, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PIVOT PHYSICAL THERAPY OF VIRGINIA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 350 NEW FIDELITY CT | ||||||||
| Address2: | |||||||||
| City: | GARNER | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275292665 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192582714 | ||||||||
| FaxNumber: | 4106484878 | ||||||||
| Practice Location | |||||||||
| Address1: | 10438 IRON BRIDGE RD UNIT 34 | ||||||||
| Address2: | |||||||||
| City: | CHESTER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 238311427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8047961518 | ||||||||
| FaxNumber: | 8047961543 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/26/2008 | ||||||||
| LastUpdateDate: | 05/05/2020 | ||||||||
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| AuthorizedOfficialLastName: | PEARSON | ||||||||
| AuthorizedOfficialFirstName: | PENNY | ||||||||
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| AuthorizedOfficialTitleorPosition: | RCM DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4432254492 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | VA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1669627048 | 01 | VA | BCBS (OCCUPATIONAL THERAPY) | OTHER | 223951123 | 01 | VA | DEPT OF LABOR | OTHER | 1669627048 | 01 | VA | BCBS (PHYSICAL THERAPY) | OTHER |