Provider Demographics
NPI:1588623847
Name:HAVELOCK PEAK PERFORMANCE SPORTS & PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:HAVELOCK PEAK PERFORMANCE SPORTS & PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:LAURENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-356-5011
Mailing Address - Street 1:PO BOX 13609
Mailing Address - Street 2:
Mailing Address - City:NEW BERN
Mailing Address - State:NC
Mailing Address - Zip Code:28561-3609
Mailing Address - Country:US
Mailing Address - Phone:252-636-9800
Mailing Address - Fax:252-636-1945
Practice Address - Street 1:1202 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HAVELOCK
Practice Address - State:NC
Practice Address - Zip Code:28532-2405
Practice Address - Country:US
Practice Address - Phone:252-447-4005
Practice Address - Fax:252-447-4001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
N/A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7212000Medicaid
NC017XXOtherBCBSNC
NC2334172Medicare PIN