Provider Demographics
NPI:1548828205
Name:SOUTH RIVER REHABILITATION AND PERFORMANCE
Entity type:Organization
Organization Name:SOUTH RIVER REHABILITATION AND PERFORMANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:DIMITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-490-0308
Mailing Address - Street 1:38 EBCO CIR STE 106
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:VA
Mailing Address - Zip Code:22980-7344
Mailing Address - Country:US
Mailing Address - Phone:540-490-0308
Mailing Address - Fax:540-451-7064
Practice Address - Street 1:38 EBCO CIR
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:VA
Practice Address - Zip Code:22980-7344
Practice Address - Country:US
Practice Address - Phone:540-490-0308
Practice Address - Fax:540-451-7064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-29
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1407142482OtherNPI