1023344397 NPI number — TRACEY BLACK POWELL PHYSICAL THERAPIST

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 1023344397 NPI number — TRACEY BLACK POWELL PHYSICAL THERAPIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POWELL
Provider First Name:
TRACEY
Provider Middle Name:
BLACK
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHYSICAL THERAPIST
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BLACK
Provider Other First Name:
TRACEY
Provider Other Middle Name:
ELAINE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1023344397
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/30/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1130 N CHURCH ST STE 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENSBORO
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27401-1041
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1130 N CHURCH ST
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
GREENSBORO
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27401-1038
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-275-2285
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/21/2009

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:  1762 , 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: 1543A . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 7212716 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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