1316996317 NPI number — WAKE FOREST PHYSICAL THERAPY

Table of content: (NPI 1316996317)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316996317 NPI number — WAKE FOREST PHYSICAL THERAPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WAKE FOREST PHYSICAL THERAPY
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:
1316996317
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/08/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
843 WAKE FOREST BUSINESS PARK
Provider Second Line Business Mailing Address:
SUITE 110
Provider Business Mailing Address City Name:
WAKE FOREST
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27587-6577
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-570-7080
Provider Business Mailing Address Fax Number:
919-570-7081

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
843 WAKE FOREST BUSINESS PARK
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
WAKE FOREST
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27587-6577
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-570-7080
Provider Business Practice Location Address Fax Number:
919-570-7081
Provider Enumeration Date:
05/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BRISSON
Authorized Official First Name:
JASEN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
919-570-7080

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , 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: 1112Q . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 101957600 . This is a "DEPT. LABOR WORKERS COMP" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: C6034 . This is a "MEDCOST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 7659542 . This is a "AETNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com