Provider Demographics
NPI:1336215367
Name:PROFESSIONAL THERAPIES OF ROANOKE, INC.
Entity Type:Organization
Organization Name:PROFESSIONAL THERAPIES OF ROANOKE, INC.
Other - Org Name:CORA PHYSICAL THERAPY - BLACKSBURG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:C
Authorized Official - Last Name:ROUSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-221-6712
Mailing Address - Street 1:1110 SHAWNEE ROAD
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805
Mailing Address - Country:US
Mailing Address - Phone:419-221-6717
Mailing Address - Fax:419-222-0507
Practice Address - Street 1:1995 SOUTH MAIN STREET
Practice Address - Street 2:SUITE 801
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060
Practice Address - Country:US
Practice Address - Phone:540-951-2703
Practice Address - Fax:540-953-0873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2019-12-04
Deactivation Date:2019-11-08
Deactivation Code:
Reactivation Date:2019-11-27
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA192427OtherANTHEM BCBS
VA29043OtherSOUTHERN HEALTH
VAC02981Medicare PIN