Provider Demographics
NPI:1366494551
Name:CAROLINA MANUAL THERAPY LLC
Entity Type:Organization
Organization Name:CAROLINA MANUAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CAROLINA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:CANDELARIA
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:910-278-6794
Mailing Address - Street 1:301 NE 42ND ST
Mailing Address - Street 2:
Mailing Address - City:OAK ISLAND
Mailing Address - State:NC
Mailing Address - Zip Code:28465-5450
Mailing Address - Country:US
Mailing Address - Phone:910-278-6794
Mailing Address - Fax:910-278-6794
Practice Address - Street 1:618 N HOWE ST
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:NC
Practice Address - Zip Code:28461-3426
Practice Address - Country:US
Practice Address - Phone:910-278-6794
Practice Address - Fax:910-278-7694
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2675225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC079CKOtherBLUE CROSS BLUE SHIELD
NC079CKOtherBLUE CROSS BLUE SHIELD
NC2346034Medicare ID - Type Unspecified