Provider Demographics
NPI:1083928949
Name:PERFORMANCE PHYSICAL THERAPY OF STAFFORD, LLC
Entity Type:Organization
Organization Name:PERFORMANCE PHYSICAL THERAPY OF STAFFORD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LATASHA
Authorized Official - Middle Name:R
Authorized Official - Last Name:BLANTON
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:540-327-1740
Mailing Address - Street 1:2777 JEFFERSON DAVIS HWY
Mailing Address - Street 2:SUITE 109
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22554-6219
Mailing Address - Country:US
Mailing Address - Phone:540-318-8615
Mailing Address - Fax:540-318-8619
Practice Address - Street 1:2777 JEFFERSON DAVIS HWY
Practice Address - Street 2:109
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22554-8323
Practice Address - Country:US
Practice Address - Phone:540-318-8615
Practice Address - Fax:540-318-8619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-03
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305204166225100000X, 2251G0304X, 2251P0200X, 2251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatricsGroup - Single Specialty
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Single Specialty
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Single Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVAA101671OtherMEDICARE PTAN