Basic Information
| Provider Information | |||||||||
| NPI: | 1871081042 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IVYREHAB SEPT, LLC | ||||||||
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| OtherOrganizationName: | SOUTHEASTERN THERAPY FOR KIDS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4668 PEMBROKE BLVD STE 115 | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234556423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7576488562 | ||||||||
| FaxNumber: | 7576488564 | ||||||||
| Practice Location | |||||||||
| Address1: | 41 OLD OYSTER POINT RD STE E | ||||||||
| Address2: | |||||||||
| City: | NEWPORT NEWS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236027177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7572231466 | ||||||||
| FaxNumber: | 7572231467 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2018 | ||||||||
| LastUpdateDate: | 09/14/2018 | ||||||||
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| AuthorizedOfficialLastName: | MILES | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | EVP/CFO | ||||||||
| AuthorizedOfficialTelephone: | 9147778700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 |
ID Information
| ID | Type | State | Issuer | Description | 96660 | 05 | VA | MEDICAID |