Provider Demographics
NPI:1326564287
Name:PROVIDENCE PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:PROVIDENCE PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:DEITZ
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:724-288-1639
Mailing Address - Street 1:271 HICKORY POINT RD
Mailing Address - Street 2:
Mailing Address - City:HAMPSTEAD
Mailing Address - State:NC
Mailing Address - Zip Code:28443-2633
Mailing Address - Country:US
Mailing Address - Phone:724-288-1629
Mailing Address - Fax:
Practice Address - Street 1:107 TRITON LN
Practice Address - Street 2:
Practice Address - City:SURF CITY
Practice Address - State:NC
Practice Address - Zip Code:28445-6923
Practice Address - Country:US
Practice Address - Phone:910-803-2040
Practice Address - Fax:910-803-2050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-22
Last Update Date:2021-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy