Provider Demographics
NPI:1164801429
Name:BALES, JEREMY (PT)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:BALES
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 PERIMETER PARK DR
Mailing Address - Street 2:STE 200
Mailing Address - City:MORRISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27560-8442
Mailing Address - Country:US
Mailing Address - Phone:984-215-4110
Mailing Address - Fax:
Practice Address - Street 1:3001 EDWARDS MILL RD # 200
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612
Practice Address - Country:US
Practice Address - Phone:919-781-4060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-20
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP17839225100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY907MOtherFLORIDA
FLY927QOtherFLORIDA BLUE
FLAM305Medicare PIN