Basic Information
| Provider Information | |||||||||
| NPI: | 1740407527 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEASTERN PHYSICAL THERAPY, INC | ||||||||
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| OtherOrganizationName: | SPECTRUM PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5301 PROVIDENCE RD | ||||||||
| Address2: | SUITE 80 | ||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234644128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574671900 | ||||||||
| FaxNumber: | 7574677900 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 CROFTON PL | ||||||||
| Address2: | LAKE MONTICELLO | ||||||||
| City: | PALMYRA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229633300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4345899588 | ||||||||
| FaxNumber: | 4345894096 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2007 | ||||||||
| LastUpdateDate: | 05/22/2015 | ||||||||
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| AuthorizedOfficialLastName: | HARTLINE | ||||||||
| AuthorizedOfficialFirstName: | JEFF | ||||||||
| AuthorizedOfficialMiddleName: | LOWELL | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7574671900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MPT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.