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Organization
TIDEWATER PHYSICAL THERAPY, LLC
Active
Organization
TIDEWATER PHYSICAL THERAPY, LLC
Active
Other names
Pantops Physical Therapy
Organization subpart
No
Provider details
NPI number
Authorized official
TASHEDA BROUGHTON PESC (MANAGER, CREDENTIALING)
(252) 248-3313
Entity
Organization
Contact information
Practice address
1490 PANTOPS MOUNTAIN PL, SUITE 202, CHARLOTTESVILLE, VA 22911-4601
(434) 245-6472
(434) 245-6474
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
—
—
225X00000X
Occupational Therapist
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
C05954
GROUP MEDICARE PTAN
VA
Enumeration date
02/14/2017
Last updated
09/02/2025
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