Provider Demographics
NPI:1124118658
Name:GREENBRIER VALLEY PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:GREENBRIER VALLEY PHYSICAL THERAPY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:STREETER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-699-9395
Mailing Address - Street 1:484 RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32202-4912
Mailing Address - Country:US
Mailing Address - Phone:800-699-9395
Mailing Address - Fax:
Practice Address - Street 1:18228 SENECA TRAIL
Practice Address - Street 2:
Practice Address - City:MARLINTON
Practice Address - State:WV
Practice Address - Zip Code:24954
Practice Address - Country:US
Practice Address - Phone:304-799-4500
Practice Address - Fax:304-799-4501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2023-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810004589Medicaid
WV=========OtherWV WORKERS COMP
WV3810004589Medicaid
WV4169720002Medicare NSC