Provider Demographics
NPI:1437202793
Name:KEMPSVILLE PHYSICAL THERAPY P C
Entity Type:Organization
Organization Name:KEMPSVILLE PHYSICAL THERAPY P C
Other - Org Name:KEMPSVILLE PHYSICAL THEGRP
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:CAROL
Authorized Official - Last Name:NIECE-BOAZ
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:757-523-4705
Mailing Address - Street 1:5265 PROVIDENCE RD
Mailing Address - Street 2:SUITE 503
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-4206
Mailing Address - Country:US
Mailing Address - Phone:757-961-7430
Mailing Address - Fax:757-523-4653
Practice Address - Street 1:5265 PROVIDENCE RD
Practice Address - Street 2:SUITE 503
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-4206
Practice Address - Country:US
Practice Address - Phone:757-523-4705
Practice Address - Fax:757-523-4653
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305002340225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA239374OtherBC BS
VA239374OtherBC BS