Basic Information
| Provider Information | |||||||||
| NPI: | 1871929729 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OLD DOMINION UNIVERSITY | ||||||||
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| OtherOrganizationName: | ODU MONARCH PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1015 W 47TH ST | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235290001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7576837041 | ||||||||
| FaxNumber: | 7576837138 | ||||||||
| Practice Location | |||||||||
| Address1: | 1015 W 47TH ST | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235290001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7576837041 | ||||||||
| FaxNumber: | 7576837050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2013 | ||||||||
| LastUpdateDate: | 07/19/2021 | ||||||||
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| AuthorizedOfficialLastName: | KOPERNA | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINIC DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7576837041 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OLD DOMINION UNIVERSITY | ||||||||
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| AuthorizedOfficialCredential: | DPT | ||||||||
| NPICertificationDate: | 07/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 235Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.