Provider Demographics
NPI:1780864199
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:MR
Authorized Official - First Name:JEFFREU
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 1:13190 JAMES MADISON HWY
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:VA
Practice Address - Zip Code:22960-2808
Practice Address - Country:US
Practice Address - Phone:540-672-2708
Practice Address - Fax:540-672-2709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
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