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Organization
TIDEWATER PHYSICAL THERAPY, LLC
Active
Organization
TIDEWATER PHYSICAL THERAPY, LLC
Active
Other names
Pivot Physical Therapy of Virginia
Organization subpart
No
Provider details
NPI number
Authorized official
TASHEDA BROUGHTON PESC (MANAGER, CREDENTIALING)
(252) 248-3313
Entity
Organization
Contact information
Practice address
10438 IRON BRIDGE RD UNIT 34, CHESTER, VA 23831-1427
(804) 796-1518
(804) 796-1543
Mailing address
2122 YORK RD STE 300, OAK BROOK, IL 60523-1925
(252) 248-3133
(410) 648-4878
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
—
VA
225X00000X
Occupational Therapist
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1669627048
BCBS (PHYSICAL THERAPY)
VA
01
—
223951123
DEPT OF LABOR
VA
Enumeration date
11/26/2008
Last updated
11/25/2024
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