Provider Demographics
NPI:1598177214
Name:ADVANCED PHYSICAL THERAPY OF CLINTON LLC
Entity Type:Organization
Organization Name:ADVANCED PHYSICAL THERAPY OF CLINTON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SKULAVIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-300-5040
Mailing Address - Street 1:317 NORTH BLVD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NC
Mailing Address - Zip Code:28328
Mailing Address - Country:US
Mailing Address - Phone:910-249-4040
Mailing Address - Fax:910-249-9250
Practice Address - Street 1:317 NORTH BLVD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NC
Practice Address - Zip Code:28328-1911
Practice Address - Country:US
Practice Address - Phone:910-249-4040
Practice Address - Fax:910-249-9250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-29
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10731261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1598177214Medicaid
NCE140Medicare PIN