Provider Demographics
NPI:1659370625
Name:LIGHT, RONNIE RUSH (PT)
Entity Type:Individual
Prefix:
First Name:RONNIE
Middle Name:RUSH
Last Name:LIGHT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:738 NEWMAN RD
Mailing Address - Street 2:
Mailing Address - City:NEW BERN
Mailing Address - State:NC
Mailing Address - Zip Code:28562-5238
Mailing Address - Country:US
Mailing Address - Phone:252-634-2676
Mailing Address - Fax:252-633-3502
Practice Address - Street 1:738 NEWMAN RD
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562-5238
Practice Address - Country:US
Practice Address - Phone:252-634-2676
Practice Address - Fax:252-633-3502
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1385225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7212399Medicaid
NC0791XOtherBCBSNC
NC7212399Medicaid