Provider Demographics
NPI:1558546184
Name:JACKSONVILLE PHYSICAL THERAPY CENTER, INC.
Entity Type:Organization
Organization Name:JACKSONVILLE PHYSICAL THERAPY CENTER, INC.
Other - Org Name:JACKSONVILLE PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:MINER
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:910-353-9800
Mailing Address - Street 1:2453 GUM BRANCH RD STE 600
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540-4538
Mailing Address - Country:US
Mailing Address - Phone:910-353-9800
Mailing Address - Fax:910-455-2083
Practice Address - Street 1:2453 GUM BRANCH RD
Practice Address - Street 2:SUITE 600
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28540-4574
Practice Address - Country:US
Practice Address - Phone:910-353-9800
Practice Address - Fax:910-455-2083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-02
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2335767Medicare UPIN