1336492297 NPI number — ELEVATE PHYSICAL THERAPY & PAIN CENTER INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336492297 NPI number — ELEVATE PHYSICAL THERAPY & PAIN CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELEVATE PHYSICAL THERAPY & PAIN CENTER 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:
1336492297
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/30/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4 MARKET ST STE 4103
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BREVARD
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28712-5636
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-342-7358
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4 MARKET ST
Provider Second Line Business Practice Location Address:
SUITE 4103
Provider Business Practice Location Address City Name:
BREVARD
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28712-5635
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-877-2110
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/16/2012

Additional Information

Authorized Official

Authorized Official Last Name:
BLAKELY
Authorized Official First Name:
MARK
Authorized Official Middle Name:
HERBERT
Authorized Official Title or Position:
OWNER/PHYSICAL THERAPIST
Authorized Official Telephone Number:
828-342-7358

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  8721 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 7217 , 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: 078RG . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 078RC . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 7211277 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: B8364 . This is a "MEDCOST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: B8363 . This is a "MEDCOST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 7211281 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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