Provider Demographics
NPI:1639731136
Name:PHOENIX PHYSICAL THERAPY & WELLNESS CENTER, INC
Entity Type:Organization
Organization Name:PHOENIX PHYSICAL THERAPY & WELLNESS CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:ANGEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BALLENTINE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:919-410-7312
Mailing Address - Street 1:705 KEYSTONE PARK DR UNIT 22
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27560-6101
Mailing Address - Country:US
Mailing Address - Phone:919-410-7312
Mailing Address - Fax:
Practice Address - Street 1:500 BENSON RD STE 114
Practice Address - Street 2:
Practice Address - City:GARNER
Practice Address - State:NC
Practice Address - Zip Code:27529-3947
Practice Address - Country:US
Practice Address - Phone:919-323-8888
Practice Address - Fax:855-554-1184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-03
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1639731136Medicaid