Provider Demographics
NPI:1285815191
Name:OUTER BANKS PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:OUTER BANKS PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPY
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:M
Authorized Official - Last Name:DOUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-255-5348
Mailing Address - Street 1:102 PINNACLE CT
Mailing Address - Street 2:
Mailing Address - City:KITTY HAWK
Mailing Address - State:NC
Mailing Address - Zip Code:27949-5911
Mailing Address - Country:US
Mailing Address - Phone:252-255-5348
Mailing Address - Fax:
Practice Address - Street 1:102 PINNACLE CT
Practice Address - Street 2:
Practice Address - City:KITTY HAWK
Practice Address - State:NC
Practice Address - Zip Code:27949-5911
Practice Address - Country:US
Practice Address - Phone:252-255-5348
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-19
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2399174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2504083Medicare PIN