Provider Demographics
NPI:1659141703
Name:CHANGE THE GAME PERFORMANCE THERAPY, INC.
Entity Type:Organization
Organization Name:CHANGE THE GAME PERFORMANCE THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GODFREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-292-8976
Mailing Address - Street 1:9080 SOUTHERN BLVD SE
Mailing Address - Street 2:
Mailing Address - City:WINNABOW
Mailing Address - State:NC
Mailing Address - Zip Code:28479-5016
Mailing Address - Country:US
Mailing Address - Phone:315-292-8976
Mailing Address - Fax:
Practice Address - Street 1:805 N 4TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-3471
Practice Address - Country:US
Practice Address - Phone:315-292-8976
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy