Provider Demographics
NPI:1124057211
Name:CHURCHLAND PHYSICAL THERAPY SERVICES, INC
Entity type:Organization
Organization Name:CHURCHLAND PHYSICAL THERAPY SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOYTEK
Authorized Official - Suffix:JR
Authorized Official - Credentials:PHYSICAL THERAPIST
Authorized Official - Phone:757-483-0333
Mailing Address - Street 1:5900 CHURCHLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23703-3313
Mailing Address - Country:US
Mailing Address - Phone:757-483-0333
Mailing Address - Fax:757-483-9359
Practice Address - Street 1:5900 CHURCHLAND BLVD
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23703-3313
Practice Address - Country:US
Practice Address - Phone:757-483-0333
Practice Address - Fax:757-483-9359
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305000773225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA200327OtherOPTIMA MEDICARE
VA325835OtherMDIPA
VA191880OtherANTHEM BLUE CROSS
VA371787OtherMDIPA
VA808578OtherMPN
VA150870400OtherU.S.DEPT OF LABOR
VA26207OtherOPTIMA PPO
VA371787OtherMDIPA