1912439464 NPI number — MICAH GREGORY MERRITT

Table of content: (NPI 1912439464)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912439464 NPI number — MICAH GREGORY MERRITT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICAH GREGORY MERRITT
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:
RENEW HEALTH AND PHYSICAL THERAPY
Provider Other Organization Name Type Code:
3
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:
1912439464
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/07/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
812 PINCKNEY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHITEVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28472-3308
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-207-6696
Provider Business Mailing Address Fax Number:
910-207-6773

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
812 PINCKNEY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHITEVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28472-3308
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-207-6696
Provider Business Practice Location Address Fax Number:
910-207-6773
Provider Enumeration Date:
04/03/2017

Additional Information

Authorized Official

Authorized Official Last Name:
MERRITT
Authorized Official First Name:
MICAH
Authorized Official Middle Name:
GREGORY
Authorized Official Title or Position:
PHYSICAL THERAPIST/OWNER
Authorized Official Telephone Number:
910-207-6696

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  P11666 , 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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