1780045419 NPI number — ELMORE CENTER FOR PHYSICAL THERAPY AND LYMPHEDEMA SERVICES

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 1780045419 NPI number — ELMORE CENTER FOR PHYSICAL THERAPY AND LYMPHEDEMA SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELMORE CENTER FOR PHYSICAL THERAPY AND LYMPHEDEMA SERVICES
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:
1780045419
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/13/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15 FLOWERING APRICOT DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DURHAM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27703-6362
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-885-9135
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7417 KNIGHTDALE BLVD
Provider Second Line Business Practice Location Address:
SUITE#103
Provider Business Practice Location Address City Name:
KNIGHTDALE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27545-8824
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-217-2000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/08/2016

Additional Information

Authorized Official

Authorized Official Last Name:
ELMORE
Authorized Official First Name:
BROOKE
Authorized Official Middle Name:
MIRANDA
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
919-885-9135

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  P14582 , 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)





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