Provider Demographics
NPI:1073835765
Name:GREG OTT'S CENTER FOR PHYSICAL THERAPY AND SPORTS PERFORMANCE, LLC
Entity Type:Organization
Organization Name:GREG OTT'S CENTER FOR PHYSICAL THERAPY AND SPORTS PERFORMANCE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:STREETER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-699-9395
Mailing Address - Street 1:PO BOX 932184
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-2184
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:449 N WENDOVER RD
Practice Address - Street 2:SUITE B
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1064
Practice Address - Country:US
Practice Address - Phone:704-366-7723
Practice Address - Fax:704-366-7724
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-22
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC022X6OtherBCBSNC
NC7200337Medicaid
NC2506130AMedicare PIN
NC6366590001Medicare NSC