1013451301 NPI number — PHOENIX PHYSICAL THERAPY AND SPORTS PERFORMANCE -LAKE NORMAN

Table of content: (NPI 1013451301)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013451301 NPI number — PHOENIX PHYSICAL THERAPY AND SPORTS PERFORMANCE -LAKE NORMAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHOENIX PHYSICAL THERAPY AND SPORTS PERFORMANCE -LAKE NORMAN
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:
1013451301
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/06/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
290 N HIGHWAY 16
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DENVER
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28037-8011
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-483-0777
Provider Business Mailing Address Fax Number:
704-483-1883

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7825 NC HIGHWAY 150 E STE 6
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TERRELL
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28682-8703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-483-0777
Provider Business Practice Location Address Fax Number:
704-483-1883
Provider Enumeration Date:
12/06/2016

Additional Information

Authorized Official

Authorized Official Last Name:
VAUGHAN
Authorized Official First Name:
JOSHUA
Authorized Official Middle Name:
D
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
704-483-0777

Provider Taxonomy Codes

  • Taxonomy code: 2251X0800X , with the licence number:  P14807 , 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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