Provider Demographics
NPI:1740407527
Name:SOUTHEASTERN PHYSICAL THERAPY, INC
Entity Type:Organization
Organization Name:SOUTHEASTERN PHYSICAL THERAPY, INC
Other - Org Name:SPECTRUM PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:LOWELL
Authorized Official - Last Name:HARTLINE
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:757-467-1900
Mailing Address - Street 1:5301 PROVIDENCE RD
Mailing Address - Street 2:SUITE 80
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-4128
Mailing Address - Country:US
Mailing Address - Phone:757-467-1900
Mailing Address - Fax:757-467-7900
Practice Address - Street 1:100 CROFTON PL
Practice Address - Street 2:LAKE MONTICELLO
Practice Address - City:PALMYRA
Practice Address - State:VA
Practice Address - Zip Code:22963-3300
Practice Address - Country:US
Practice Address - Phone:434-589-9588
Practice Address - Fax:434-589-4096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA496660Medicare PIN