Provider Demographics
NPI:1275074163
Name:PORTER'S NECK PHYSICAL THERAPY AND WELLNESS, LLC
Entity Type:Organization
Organization Name:PORTER'S NECK PHYSICAL THERAPY AND WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, MSPT, MSGRT
Authorized Official - Phone:910-508-1829
Mailing Address - Street 1:8262 MARKET ST STE 103
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28411-9681
Mailing Address - Country:US
Mailing Address - Phone:910-508-1829
Mailing Address - Fax:
Practice Address - Street 1:8262 MARKET ST STE 103
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28411-9681
Practice Address - Country:US
Practice Address - Phone:910-508-1829
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PORTER'S NECK PHYSICAL THERAPY AND WELLNESS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-03-13
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCPT 10998225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCQ428730281Medicare UPIN