Provider Demographics
NPI:1437605169
Name:SELECT PHYSICAL THERAPY
Entity Type:Organization
Organization Name:SELECT PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CENTER MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:STICKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-366-5521
Mailing Address - Street 1:2826 RANDOLPH RD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211
Mailing Address - Country:US
Mailing Address - Phone:704-366-5521
Mailing Address - Fax:
Practice Address - Street 1:2826 RANDOLPH RD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211
Practice Address - Country:US
Practice Address - Phone:704-366-5521
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SELECT MEDICAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC16489261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
346569Medicare PIN