Provider Demographics
NPI:1003994054
Name:FAYETTEVILLE PHYSICAL THERAPY & SPORTS REHABILITATION
Entity Type:Organization
Organization Name:FAYETTEVILLE PHYSICAL THERAPY & SPORTS REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:M
Authorized Official - Last Name:BRANDSTETTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-574-1416
Mailing Address - Street 1:233 N COURT ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25840-1233
Mailing Address - Country:US
Mailing Address - Phone:304-574-1416
Mailing Address - Fax:304-574-1474
Practice Address - Street 1:233 N COURT ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:WV
Practice Address - Zip Code:25840-1233
Practice Address - Country:US
Practice Address - Phone:304-574-1416
Practice Address - Fax:304-574-1474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV902174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0156959000Medicaid
WV1459717OtherUMWA
WV0156959000Medicaid