Basic Information
| Provider Information | |||||||||
| NPI: | 1215462775 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COASTAL VIRGINIA REHABILITATION, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RIVERSIDE REHABILITATION HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4714 GETTYSBURG RD | ||||||||
| Address2: | LEGAL DEPT | ||||||||
| City: | MECHANICSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170554325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7179721100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 245 CHESAPEAKE AVE | ||||||||
| Address2: | |||||||||
| City: | NEWPORT NEWS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236076038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7179721100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2017 | ||||||||
| LastUpdateDate: | 11/25/2019 | ||||||||
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| AuthorizedOfficialLastName: | TARVIN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7179721100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283X00000X | Y | Hospitals | Rehabilitation Hospital |
No ID Information.