Basic Information
| Provider Information | |||||||||
| NPI: | 1003890815 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REHABILITATION SERVICES OF DANVILLE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | REHABILITATION SERVICES OF DANVILLE, LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8833 | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240140745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407728022 | ||||||||
| FaxNumber: | 5407720294 | ||||||||
| Practice Location | |||||||||
| Address1: | 990 MAIN ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | DANVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407728022 | ||||||||
| FaxNumber: | 5407720294 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2005 | ||||||||
| LastUpdateDate: | 07/15/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LUCAS | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 5407728022 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 0105000005 | VA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 193529 | 01 | VA | ANTHEM BCBS | OTHER | 4978269 | 05 | VA | MEDICAID |