Provider Demographics
NPI:1356653133
Name:PRINCE WILLIAM PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:PRINCE WILLIAM PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:W
Authorized Official - Last Name:BREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-368-4040
Mailing Address - Street 1:12613 VICTORY LAKES LOOP
Mailing Address - Street 2:
Mailing Address - City:BRISTOW
Mailing Address - State:VA
Mailing Address - Zip Code:20136-1274
Mailing Address - Country:US
Mailing Address - Phone:703-361-7940
Mailing Address - Fax:703-361-1177
Practice Address - Street 1:8565 SUDLEY RD STE A
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-3864
Practice Address - Country:US
Practice Address - Phone:703-368-4040
Practice Address - Fax:703-361-1177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-08
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305004656261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy