Provider Demographics
NPI:1598142440
Name:HORTON, PHILLIP GARY SR
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:GARY
Last Name:HORTON
Suffix:SR
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:PHILLIP
Other - Middle Name:
Other - Last Name:HORTON
Other - Suffix:SR
Other - Last Name Type:Professional Name
Other - Credentials:ATC / L
Mailing Address - Street 1:PO BOX 2164
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28070-2164
Mailing Address - Country:US
Mailing Address - Phone:704-960-9296
Mailing Address - Fax:704-875-9293
Practice Address - Street 1:12152 MOONSHADOW LN
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-6858
Practice Address - Country:US
Practice Address - Phone:704-960-9296
Practice Address - Fax:704-875-9293
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-29
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1 - 101246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other