Provider Demographics
NPI:1518017540
Name:MERRITT PHYSICAL THERAPY & REHABILITATION
Entity Type:Organization
Organization Name:MERRITT PHYSICAL THERAPY & REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-935-6496
Mailing Address - Street 1:PO BOX 1078
Mailing Address - Street 2:
Mailing Address - City:GRUNDY
Mailing Address - State:VA
Mailing Address - Zip Code:24614-1078
Mailing Address - Country:US
Mailing Address - Phone:276-935-6496
Mailing Address - Fax:276-935-5852
Practice Address - Street 1:20716 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:GRUNDY
Practice Address - State:VA
Practice Address - Zip Code:24614-6747
Practice Address - Country:US
Practice Address - Phone:276-935-6496
Practice Address - Fax:276-935-5852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119003456225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA193488OtherANTHEM OT
VA004978471Medicaid
VA004978471Medicaid