Provider Demographics
NPI:1992766315
Name:MARTINSVILLE PHYSICAL THERAPY & INDUSTRIAL REHABILITATION INC
Entity type:Organization
Organization Name:MARTINSVILLE PHYSICAL THERAPY & INDUSTRIAL REHABILITATION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TOMMY
Authorized Official - Middle Name:DIRE
Authorized Official - Last Name:MATHENA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-836-4158
Mailing Address - Street 1:PO BOX 4018
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24540
Mailing Address - Country:US
Mailing Address - Phone:434-836-4158
Mailing Address - Fax:434-836-0250
Practice Address - Street 1:812 E. CHURCH STREET
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112
Practice Address - Country:US
Practice Address - Phone:276-638-4809
Practice Address - Fax:276-638-5139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-28
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305005523225100000X
VA23005523225100000X
225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004978790Medicaid
VA496585Medicare UPIN