1144406539 NPI number — PHYSICAL THERAPY FOR WOMEN, INC

Table of content: (NPI 1144406539)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144406539 NPI number — PHYSICAL THERAPY FOR WOMEN, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICAL THERAPY FOR WOMEN, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144406539
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/27/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5919 OLEANDER DR
Provider Second Line Business Mailing Address:
SUITE 123
Provider Business Mailing Address City Name:
WILMINGTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28403-4780
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-798-2318
Provider Business Mailing Address Fax Number:
910-798-2319

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1630 MILITARY CUTOFF RD STE 110
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28403-5719
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-798-2318
Provider Business Practice Location Address Fax Number:
910-798-2319
Provider Enumeration Date:
01/15/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SHEPHERD
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OWNER/PHYSICAL THERAPIST
Authorized Official Telephone Number:
910-798-2318

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  4865 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7211054 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 017WJ . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 2320258 . This is a "HUMANA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".