Provider Demographics
NPI:1871513788
Name:DOMINION HEALTH & FITNESS, INC
Entity type:Organization
Organization Name:DOMINION HEALTH & FITNESS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BERNARD
Authorized Official - Middle Name:P
Authorized Official - Last Name:DHAS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:276-926-4516
Mailing Address - Street 1:PO BOX 1810
Mailing Address - Street 2:
Mailing Address - City:CLINTWOOD
Mailing Address - State:VA
Mailing Address - Zip Code:24228-1810
Mailing Address - Country:US
Mailing Address - Phone:276-926-4516
Mailing Address - Fax:276-926-6652
Practice Address - Street 1:4862 DICKENSON HWY
Practice Address - Street 2:
Practice Address - City:CLINTWOOD
Practice Address - State:VA
Practice Address - Zip Code:24228-1810
Practice Address - Country:US
Practice Address - Phone:276-926-4516
Practice Address - Fax:276-926-6652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010193885Medicaid
VA196257OtherANTHEM GROUP PROVIDER #
VA1201827OtherCHA HEALTH PROVIDER #
VA3782625OtherAETNA HEALTHCARE #
VA496705Medicare PIN
VA496705Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER