Provider Demographics
NPI:1376722645
Name:ACKISS PHYSICAL THERAPY
Entity Type:Organization
Organization Name:ACKISS PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:DILLAN
Authorized Official - Last Name:ACKISS
Authorized Official - Suffix:
Authorized Official - Credentials:PT, MS, OCS
Authorized Official - Phone:757-963-5949
Mailing Address - Street 1:700 NEWTOWN RD
Mailing Address - Street 2:SUITE 9
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-3925
Mailing Address - Country:US
Mailing Address - Phone:757-963-5949
Mailing Address - Fax:757-963-6472
Practice Address - Street 1:700 NEWTOWN RD
Practice Address - Street 2:SUITE 9
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-3925
Practice Address - Country:US
Practice Address - Phone:757-963-5949
Practice Address - Fax:757-963-6472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-02
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305004384225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC09751Medicare PIN