Provider Demographics
NPI:1003204934
Name:GRIDIRON247
Entity Type:Organization
Organization Name:GRIDIRON247
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JERRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MCPHAIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-525-3088
Mailing Address - Street 1:210 W MARTIN LUTHER KING BLVD
Mailing Address - Street 2:
Mailing Address - City:ROSEBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28382-9066
Mailing Address - Country:US
Mailing Address - Phone:910-525-3088
Mailing Address - Fax:
Practice Address - Street 1:210 W MARTIN L. KING BLVD
Practice Address - Street 2:
Practice Address - City:ROSEBORO
Practice Address - State:NC
Practice Address - Zip Code:28382-9066
Practice Address - Country:US
Practice Address - Phone:910-525-3088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-30
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty