Provider Demographics
NPI:1942791439
Name:BPT WELLNESS
Entity Type:Organization
Organization Name:BPT WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BROADWIN
Authorized Official - Middle Name:B
Authorized Official - Last Name:ADESEGUN
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:703-826-3743
Mailing Address - Street 1:657 NATHANIEL CHASE LN
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-4970
Mailing Address - Country:US
Mailing Address - Phone:703-826-3743
Mailing Address - Fax:
Practice Address - Street 1:657 NATHANIEL CHASE LN
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-4970
Practice Address - Country:US
Practice Address - Phone:571-235-7898
Practice Address - Fax:206-339-2959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-21
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305204402225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty