Provider Demographics
NPI:1003666959
Name:IRON VARSITY, LLC
Entity Type:Organization
Organization Name:IRON VARSITY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:COLTON
Authorized Official - Middle Name:WALKER
Authorized Official - Last Name:OWCZARZAK
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:831-524-2966
Mailing Address - Street 1:5132 DOUGHTYMEWS LN
Mailing Address - Street 2:
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-7672
Mailing Address - Country:US
Mailing Address - Phone:831-524-2966
Mailing Address - Fax:
Practice Address - Street 1:5132 DOUGHTYMEWS LN
Practice Address - Street 2:
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-7672
Practice Address - Country:US
Practice Address - Phone:831-524-2966
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty