Provider Demographics
NPI:1114082922
Name:ABC PEDIATRIC REHAB
Entity Type:Organization
Organization Name:ABC PEDIATRIC REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OCCUPATIONAL THERAPY
Authorized Official - Prefix:MR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:EDGAR
Authorized Official - Last Name:WOLFE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MS OTR L
Authorized Official - Phone:704-771-0051
Mailing Address - Street 1:PO BOX 691775
Mailing Address - Street 2:
Mailing Address - City:MINT HILL
Mailing Address - State:NC
Mailing Address - Zip Code:28227-7030
Mailing Address - Country:US
Mailing Address - Phone:704-771-0051
Mailing Address - Fax:800-806-9071
Practice Address - Street 1:10620 STONE BUNKER DRIVE
Practice Address - Street 2:
Practice Address - City:MINT HILL
Practice Address - State:NC
Practice Address - Zip Code:28227
Practice Address - Country:US
Practice Address - Phone:704-771-0051
Practice Address - Fax:800-806-9071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10550225100000X
NC5989225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7212058Medicaid