Provider Demographics
NPI:1083099394
Name:CHILDREN'S PLACE PEDIATRIC THERAPIES, LLC
Entity Type:Organization
Organization Name:CHILDREN'S PLACE PEDIATRIC THERAPIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAMITA
Authorized Official - Middle Name:
Authorized Official - Last Name:WATKINS-AMICK
Authorized Official - Suffix:
Authorized Official - Credentials:MPT, DPT
Authorized Official - Phone:336-382-9797
Mailing Address - Street 1:5760 BUNCH RD
Mailing Address - Street 2:
Mailing Address - City:OAK RIDGE
Mailing Address - State:NC
Mailing Address - Zip Code:27310-9742
Mailing Address - Country:US
Mailing Address - Phone:336-382-9797
Mailing Address - Fax:
Practice Address - Street 1:5760 BUNCH RD
Practice Address - Street 2:
Practice Address - City:OAK RIDGE
Practice Address - State:NC
Practice Address - Zip Code:27310-9742
Practice Address - Country:US
Practice Address - Phone:336-382-9797
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-28
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP13476261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation