Provider Demographics
NPI:1316563943
Name:PLATINUM THERAPY & PERFORMANCE CENTER LLC
Entity Type:Organization
Organization Name:PLATINUM THERAPY & PERFORMANCE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:ATC, LAT
Authorized Official - Phone:910-740-5882
Mailing Address - Street 1:296 BAXLEY RD
Mailing Address - Street 2:
Mailing Address - City:SAINT PAULS
Mailing Address - State:NC
Mailing Address - Zip Code:28384-6766
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:296 BAXLEY RD
Practice Address - Street 2:
Practice Address - City:SAINT PAULS
Practice Address - State:NC
Practice Address - Zip Code:28384-6766
Practice Address - Country:US
Practice Address - Phone:910-740-5882
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-19
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty