Provider Demographics
NPI:1578671681
Name:PHYSCIAL AND AQUATIC THERAPY, INC.
Entity Type:Organization
Organization Name:PHYSCIAL AND AQUATIC THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:KAZALAS
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:304-235-4300
Mailing Address - Street 1:54 W 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSON
Mailing Address - State:WV
Mailing Address - Zip Code:25661-3508
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:54 W 3RD AVE
Practice Address - Street 2:
Practice Address - City:WILLIAMSON
Practice Address - State:WV
Practice Address - Zip Code:25661-3508
Practice Address - Country:US
Practice Address - Phone:304-235-4300
Practice Address - Fax:304-235-0176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-28
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
001723120OtherPIN #
001711463OtherBLUE CROSS/BLUE SHIELD GP
=========OtherTAX IDENTIFICATION
WVPH9358661Medicare ID - Type UnspecifiedWEST VIRGINIA MEDICARE