Provider Demographics
NPI:1720028459
Name:FIRST COLONY REHAB, LLC
Entity Type:Organization
Organization Name:FIRST COLONY REHAB, LLC
Other - Org Name:TIDEWAY PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENDALL
Authorized Official - Middle Name:
Authorized Official - Last Name:GILL
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:817-929-1420
Mailing Address - Street 1:PO BOX 3106
Mailing Address - Street 2:
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77552-0106
Mailing Address - Country:US
Mailing Address - Phone:409-741-8472
Mailing Address - Fax:409-741-2342
Practice Address - Street 1:6444 CENTRAL CITY BLVD
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77551-2058
Practice Address - Country:US
Practice Address - Phone:409-741-8472
Practice Address - Fax:409-741-2342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00430XMedicare ID - Type Unspecified