Provider Demographics
NPI:1841399425
Name:WINCHESTER PHYSICAL THERAPY & SPORTS MEDICINE, INC.
Entity Type:Organization
Organization Name:WINCHESTER PHYSICAL THERAPY & SPORTS MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:T
Authorized Official - Last Name:HUMPHREYS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:540-667-7076
Mailing Address - Street 1:130 MEDICAL CIR
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-3322
Mailing Address - Country:US
Mailing Address - Phone:540-667-7076
Mailing Address - Fax:540-667-5773
Practice Address - Street 1:130 MEDICAL CIR
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-3322
Practice Address - Country:US
Practice Address - Phone:540-667-7076
Practice Address - Fax:540-667-5773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305001499174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA3810004945Medicaid
WV3810004944Medicaid
VAC05983Medicare ID - Type UnspecifiedPHYSICAL THERAPY CLINIC