Provider Demographics
NPI:1730463035
Name:LILLINGTON PHYSICAL THERAPY
Entity Type:Organization
Organization Name:LILLINGTON PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:LEAIRD
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:321-698-6819
Mailing Address - Street 1:144 ADCOCK RD
Mailing Address - Street 2:
Mailing Address - City:LILLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27546-9236
Mailing Address - Country:US
Mailing Address - Phone:910-814-5885
Mailing Address - Fax:910-814-8558
Practice Address - Street 1:55 BAIN STREET
Practice Address - Street 2:SUITE 101
Practice Address - City:LILLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27546-9236
Practice Address - Country:US
Practice Address - Phone:910-814-5885
Practice Address - Fax:910-814-8558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-05
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6118225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC12012313OtherCAQH
NC1730463035OtherNPI
NC1730463035OtherNPI