Provider Demographics
NPI:1437580834
Name:EXCEL PHYSICAL THERAPY AND SPORTS PERFORMANCE, LLC
Entity Type:Organization
Organization Name:EXCEL PHYSICAL THERAPY AND SPORTS PERFORMANCE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:304-881-5042
Mailing Address - Street 1:3540 TEAYS VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526-9054
Mailing Address - Country:US
Mailing Address - Phone:304-881-5042
Mailing Address - Fax:304-562-7821
Practice Address - Street 1:3540 TEAYS VALLEY RD
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-9054
Practice Address - Country:US
Practice Address - Phone:304-881-5042
Practice Address - Fax:304-562-7821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-10
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV02111261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation