Provider Demographics
NPI:1225541568
Name:TRI-COUNTY SPORTS & REHAB
Entity Type:Organization
Organization Name:TRI-COUNTY SPORTS & REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:ORTA
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:336-258-8252
Mailing Address - Street 1:2015 N BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:ELKIN
Mailing Address - State:NC
Mailing Address - Zip Code:28621-2107
Mailing Address - Country:US
Mailing Address - Phone:336-258-8252
Mailing Address - Fax:336-258-8253
Practice Address - Street 1:2015 N BRIDGE ST
Practice Address - Street 2:
Practice Address - City:ELKIN
Practice Address - State:NC
Practice Address - Zip Code:28621-2107
Practice Address - Country:US
Practice Address - Phone:336-258-8252
Practice Address - Fax:336-258-8253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-08
Last Update Date:2017-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP48622251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890281HMedicaid