1790096485 NPI number — PHYSICAL THERAPY OF THE TRIAD, CORP.

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 1790096485 NPI number — PHYSICAL THERAPY OF THE TRIAD, CORP.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICAL THERAPY OF THE TRIAD, CORP.
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:
1790096485
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4628 RIVER VALLEY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HIGH POINT
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27265-9295
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-391-7892
Provider Business Mailing Address Fax Number:
336-665-8446

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4628 RIVER VALLEY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HIGH POINT
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27265-9295
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-391-7892
Provider Business Practice Location Address Fax Number:
336-665-8446
Provider Enumeration Date:
06/28/2010

Additional Information

Authorized Official

Authorized Official Last Name:
LEATHERMAN
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
EUGENE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
336-391-7892

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  8012 , 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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