1770776692 NPI number — MARC CHARLES MODICA LPT

Table of content: MARC CHARLES MODICA LPT (NPI 1770776692)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770776692 NPI number — MARC CHARLES MODICA LPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MODICA
Provider First Name:
MARC
Provider Middle Name:
CHARLES
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPT
Provider Gender Code:
M

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:
1770776692
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/29/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
304 NEW LEICESTER HWY. SUITE B
Provider Second Line Business Mailing Address:
PHYSICAL THERAPY AND BACK CLINIC OF LEICESTER
Provider Business Mailing Address City Name:
ASHEVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28806-9517
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-225-3838
Provider Business Mailing Address Fax Number:
828-225-3839

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
304 NEW LEICESTER HWY. SUITE B
Provider Second Line Business Practice Location Address:
PHYSICAL THERAPY AND BACK CLINIC OF LEICESTER
Provider Business Practice Location Address City Name:
ASHEVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28806-9517
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-225-3838
Provider Business Practice Location Address Fax Number:
828-225-3839
Provider Enumeration Date:
08/23/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  4614 , 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: 6743 . This is a "BCBS PIN" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".