Provider Demographics
NPI:1952363822
Name:ATLANTIC SPORTS & REHABILITATION SERVICES, INC
Entity Type:Organization
Organization Name:ATLANTIC SPORTS & REHABILITATION SERVICES, INC
Other - Org Name:PHYSICAL THERAPY
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:W
Authorized Official - Last Name:TULENKO
Authorized Official - Suffix:
Authorized Official - Credentials:MPT OCS
Authorized Official - Phone:434-978-4915
Mailing Address - Street 1:1410 INCARNATION DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22901-5708
Mailing Address - Country:US
Mailing Address - Phone:434-978-4915
Mailing Address - Fax:434-978-7194
Practice Address - Street 1:1410 INCARNATION DR
Practice Address - Street 2:SUITE 101
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22901-5708
Practice Address - Country:US
Practice Address - Phone:434-978-4915
Practice Address - Fax:434-978-7194
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-05
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2315014631225100000X
VA2305004631261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004980328Medicaid
496631Medicare ID - Type Unspecified
VA496631Medicare Oscar/Certification