Basic Information
| Provider Information | |||||||||
| NPI: | 1871959726 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRIMUS PHYSICAL THERAPY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6101 REDWOOD SQUARE CTR | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | CENTREVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201214265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016425096 | ||||||||
| FaxNumber: | 7039950284 | ||||||||
| Practice Location | |||||||||
| Address1: | 6101 REDWOOD SQUARE CTR | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | CENTREVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 20121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7035436660 | ||||||||
| FaxNumber: | 7039950284 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2016 | ||||||||
| LastUpdateDate: | 08/02/2018 | ||||||||
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| AuthorizedOfficialLastName: | DE CONTI | ||||||||
| AuthorizedOfficialFirstName: | JACQUELINE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CLINICAL SERVICES DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4438129890 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DPT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 230525109 | VA | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.