Provider Demographics
NPI:1306839089
Name:SOUTHSIDE THERAPY ASSOCIATES, INC.
Entity Type:Organization
Organization Name:SOUTHSIDE THERAPY ASSOCIATES, INC.
Other - Org Name:PROGRESSIVE THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF BUSINESS AFFAIRS
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:HUDGINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-392-4910
Mailing Address - Street 1:PO BOX 468
Mailing Address - Street 2:
Mailing Address - City:FARMVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23901-0468
Mailing Address - Country:US
Mailing Address - Phone:434-392-4910
Mailing Address - Fax:434-392-8793
Practice Address - Street 1:1412 W 3RD ST
Practice Address - Street 2:
Practice Address - City:FARMVILLE
Practice Address - State:VA
Practice Address - Zip Code:23901-2648
Practice Address - Country:US
Practice Address - Phone:434-392-1596
Practice Address - Fax:434-392-5201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-26
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004978889Medicaid
VA496619Medicare PIN
VA496619Medicare Oscar/Certification