Basic Information
| Provider Information | |||||||||
| NPI: | 1861098741 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PORTAL PHYSICAL THERAPY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3536 GAMAGE DRIVE, NORFOLK, VA, USA | ||||||||
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| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7575448312 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2460 E LITTLE CREEK RD UNIT B | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235183231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7575448312 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2020 | ||||||||
| LastUpdateDate: | 12/07/2020 | ||||||||
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| AuthorizedOfficialLastName: | CLARK | ||||||||
| AuthorizedOfficialFirstName: | TAYLOR | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/PHYSICAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 7575448312 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DPT | ||||||||
| NPICertificationDate: | 12/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.