Provider Demographics
NPI:1669138319
Name:PRIME PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:PRIME PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KAYLA
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:815-973-4189
Mailing Address - Street 1:7516 IRON BAR LN
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20155-2999
Mailing Address - Country:US
Mailing Address - Phone:571-261-9234
Mailing Address - Fax:757-720-8323
Practice Address - Street 1:7516 IRON BAR LN
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155-2999
Practice Address - Country:US
Practice Address - Phone:571-261-9234
Practice Address - Fax:757-720-8323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-16
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy