1104894948 NPI number — PEDIATRIC PHYSICAL THERAPY SERVICES, INC

Table of content: (NPI 1104894948)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104894948 NPI number — PEDIATRIC PHYSICAL THERAPY SERVICES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC PHYSICAL THERAPY SERVICES, INC
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:
6
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:
1104894948
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/14/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
221 COUNTRY PLACE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILMINGTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28409-4413
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-264-6889
Provider Business Mailing Address Fax Number:
910-530-3007

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
221 COUNTRY PLACE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28409-4413
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-264-6889
Provider Business Practice Location Address Fax Number:
910-530-3007
Provider Enumeration Date:
03/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RIEGLER
Authorized Official First Name:
BETH
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
PHYSICAL THERAPIST/PRESIDENT
Authorized Official Telephone Number:
910-264-6889

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  5000 , 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: 078H5 . This is a "BCBS OF NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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