Tidewater Physical Therapy, LLC

Primary specialty

Physical TherapistTaxonomy code 225100000X

Legal business name

TIDEWATER PHYSICAL THERAPY, LLC

Doing business as

Pivot Physical Therapy of Virginia

Practice address

10438 Iron Bridge Rd Unit 34
Chester, VA 23831-1427

Phone

(804) 796-1518

Fax

(804) 796-1543

NPI assigned

Nov 26, 2008

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Tasheda Broughton, PESC

Title

Manager, Credentialing

Phone

(252) 248-3313

Specialties & licenses 2

Addresses

Other identifiers 3

Other names 1

• Pivot Physical Therapy of Virginia Doing business as

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1227657600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1732492800000",
    "number": "1669627048",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2122 YORK RD STE 300",
            "city": "OAK BROOK",
            "state": "IL",
            "postal_code": "605231925",
            "telephone_number": "252-248-3133",
            "fax_number": "410-648-4878"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "10438 IRON BRIDGE RD UNIT 34",
            "city": "CHESTER",
            "state": "VA",
            "postal_code": "238311427",
            "telephone_number": "804-796-1518",
            "fax_number": "804-796-1543"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TIDEWATER PHYSICAL THERAPY, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-11-26",
        "last_updated": "2024-11-25",
        "certification_date": "2024-11-25",
        "status": "A",
        "authorized_official_last_name": "BROUGHTON",
        "authorized_official_first_name": "TASHEDA",
        "authorized_official_title_or_position": "MANAGER, CREDENTIALING",
        "authorized_official_telephone_number": "252-248-3313",
        "authorized_official_credential": "PESC"
    },
    "taxonomies": [
        {
            "code": "225100000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Physical Therapist",
            "state": "VA",
            "license": null,
            "primary": true
        },
        {
            "code": "225X00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Occupational Therapist",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS (PHYSICAL THERAPY)",
            "identifier": "1669627048",
            "state": "VA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DEPT OF LABOR",
            "identifier": "223951123",
            "state": "VA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS (OCCUPATIONAL THERAPY)",
            "identifier": "1669627048",
            "state": "VA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Pivot Physical Therapy of Virginia",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Physical Therapist in Chester, VA
• Providers in Chester, VA by specialty
• Physical Therapist in Virginia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 25, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.