Provider Demographics
NPI:1497739783
Name:COLVILLE, JOHN LYTLE (PT)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:LYTLE
Last Name:COLVILLE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4601 PARK RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-3239
Mailing Address - Country:US
Mailing Address - Phone:704-323-2000
Mailing Address - Fax:
Practice Address - Street 1:9848 NORTH TRYON STREET
Practice Address - Street 2:STE 200
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262
Practice Address - Country:US
Practice Address - Phone:704-323-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC100802251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0397730028Medicare NSC