Provider Demographics
NPI:1700503992
Name:CTL OF VA LLC
Entity type:Organization
Organization Name:CTL OF VA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-576-0786
Mailing Address - Street 1:210 PROFESSIONAL PARK DR SE STE 9
Mailing Address - Street 2:
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-6649
Mailing Address - Country:US
Mailing Address - Phone:904-616-3040
Mailing Address - Fax:
Practice Address - Street 1:210 PROFESSIONAL PARK DR SE STE 9
Practice Address - Street 2:
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-6649
Practice Address - Country:US
Practice Address - Phone:904-616-3040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-27
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty