Provider Demographics
NPI:1871081042
Name:IVYREHAB SEPT, LLC
Entity type:Organization
Organization Name:IVYREHAB SEPT, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EVP/CFO
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:MILES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-777-8700
Mailing Address - Street 1:4668 PEMBROKE BLVD STE 115
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-6423
Mailing Address - Country:US
Mailing Address - Phone:757-648-8562
Mailing Address - Fax:757-648-8564
Practice Address - Street 1:41 OLD OYSTER POINT RD STE E
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-7177
Practice Address - Country:US
Practice Address - Phone:757-223-1466
Practice Address - Fax:757-223-1467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-24
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA96660Medicaid