Provider Demographics
NPI:1861098741
Name:PORTAL PHYSICAL THERAPY
Entity type:Organization
Organization Name:PORTAL PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:TAYLOR
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:757-544-8312
Mailing Address - Street 1:3536 GAMAGE DRIVE, NORFOLK, VA, USA
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23518
Mailing Address - Country:US
Mailing Address - Phone:757-544-8312
Mailing Address - Fax:
Practice Address - Street 1:2460 E LITTLE CREEK RD UNIT B
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23518-3231
Practice Address - Country:US
Practice Address - Phone:757-544-8312
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-07
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty