Provider Demographics
NPI:1154502763
Name:GRACE PHYSICAL THERAPY, PC
Entity type:Organization
Organization Name:GRACE PHYSICAL THERAPY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:FRANCIS
Authorized Official - Last Name:BRUNO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:540-899-6863
Mailing Address - Street 1:2201 CHARLES ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-3378
Mailing Address - Country:US
Mailing Address - Phone:540-899-6863
Mailing Address - Fax:
Practice Address - Street 1:2201 CHARLES ST
Practice Address - Street 2:SUITE 105
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-3378
Practice Address - Country:US
Practice Address - Phone:540-899-6863
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-26
Last Update Date:2009-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA23050048602251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC10765Medicare PIN
VAC08607Medicare PIN