Provider Demographics
NPI:1497700918
Name:PRESTON REHABILITATION & ORTHOPEDIC PHYSICAL THERAPY, INC
Entity Type:Organization
Organization Name:PRESTON REHABILITATION & ORTHOPEDIC PHYSICAL THERAPY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:WALTON
Authorized Official - Last Name:MCNEW
Authorized Official - Suffix:III
Authorized Official - Credentials:MBA
Authorized Official - Phone:304-329-3739
Mailing Address - Street 1:421 MORGANTOWN ST
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26537-1095
Mailing Address - Country:US
Mailing Address - Phone:304-329-3739
Mailing Address - Fax:304-329-3250
Practice Address - Street 1:421 MORGANTOWN ST
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:WV
Practice Address - Zip Code:26537-1095
Practice Address - Country:US
Practice Address - Phone:304-329-3739
Practice Address - Fax:304-329-3250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV013138225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0204035000Medicaid
WV9341051Medicare ID - Type Unspecified