Provider Demographics
NPI:1003890815
Name:REHABILITATION SERVICES OF DANVILLE
Entity Type:Organization
Organization Name:REHABILITATION SERVICES OF DANVILLE
Other - Org Name:REHABILITATION SERVICES OF DANVILLE, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:LUCAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-772-8022
Mailing Address - Street 1:PO BOX 8833
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-0745
Mailing Address - Country:US
Mailing Address - Phone:540-772-8022
Mailing Address - Fax:540-772-0294
Practice Address - Street 1:990 MAIN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541
Practice Address - Country:US
Practice Address - Phone:540-772-8022
Practice Address - Fax:540-772-0294
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-05
Last Update Date:2011-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0105000005225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA193529OtherANTHEM BCBS
VA4978269Medicaid
VA496531Medicare PIN