Basic Information
Provider Information | |||||||||
NPI: | 1962154971 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TIDEWATER PHYSICAL THERAPY LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 350 NEW FIDELITY CT | ||||||||
Address2: |   | ||||||||
City: | GARNER | ||||||||
State: | NC | ||||||||
PostalCode: | 275292665 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9195784538 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 203 N WASHINGTON HWY | ||||||||
Address2: |   | ||||||||
City: | ASHLAND | ||||||||
State: | VA | ||||||||
PostalCode: | 230051623 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8047981112 | ||||||||
FaxNumber: | 8047981171 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/20/2022 | ||||||||
LastUpdateDate: | 01/20/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SPRANKLE | ||||||||
AuthorizedOfficialFirstName: | KALI | ||||||||
AuthorizedOfficialMiddleName: | N | ||||||||
AuthorizedOfficialTitleorPosition: | VP MANAGED CARE | ||||||||
AuthorizedOfficialTelephone: | 3303014964 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/20/2022 |
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 |   |
No ID Information.