Basic Information
| Provider Information | |||||||||
| NPI: | 1942791439 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BPT WELLNESS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 657 NATHANIEL CHASE LN | ||||||||
| Address2: | |||||||||
| City: | HERNDON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201704970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038263743 | ||||||||
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| Practice Location | |||||||||
| Address1: | 657 NATHANIEL CHASE LN | ||||||||
| Address2: | |||||||||
| City: | HERNDON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201704970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5712357898 | ||||||||
| FaxNumber: | 2063392959 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2018 | ||||||||
| LastUpdateDate: | 06/09/2022 | ||||||||
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| AuthorizedOfficialLastName: | ADESEGUN | ||||||||
| AuthorizedOfficialFirstName: | BROADWIN | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7038263743 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DPT | ||||||||
| NPICertificationDate: | 06/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2305204402 | VA | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.