Provider Demographics
NPI:1477846640
Name:MIDLOTHIAN REHABILITATION ASSOCIATES PLLC
Entity type:Organization
Organization Name:MIDLOTHIAN REHABILITATION ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:REDOUANE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOULMAMINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-897-3455
Mailing Address - Street 1:513 HETH CT
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23114-5532
Mailing Address - Country:US
Mailing Address - Phone:804-897-3455
Mailing Address - Fax:
Practice Address - Street 1:95 MEDICAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-9280
Practice Address - Country:US
Practice Address - Phone:804-504-8100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-22
Last Update Date:2011-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101242555208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty