Provider Demographics
NPI:1871959726
Name:PRIMUS PHYSICAL THERAPY
Entity type:Organization
Organization Name:PRIMUS PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SERVICES DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:DE CONTI
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:443-812-9890
Mailing Address - Street 1:6101 REDWOOD SQUARE CTR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20121-4265
Mailing Address - Country:US
Mailing Address - Phone:301-642-5096
Mailing Address - Fax:703-995-0284
Practice Address - Street 1:6101 REDWOOD SQUARE CTR
Practice Address - Street 2:SUITE 202
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20121
Practice Address - Country:US
Practice Address - Phone:703-543-6660
Practice Address - Fax:703-995-0284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-07
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA230525109225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty