Provider Demographics
NPI:1730658253
Name:SMART ATHLETE PHYSIOTHERAPY, LLC
Entity Type:Organization
Organization Name:SMART ATHLETE PHYSIOTHERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ANGELO
Authorized Official - Last Name:VITA
Authorized Official - Suffix:JR
Authorized Official - Credentials:PT, DPT, ECS
Authorized Official - Phone:919-624-2358
Mailing Address - Street 1:5153 FAIRMEAD CIR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27613-7858
Mailing Address - Country:US
Mailing Address - Phone:919-424-6055
Mailing Address - Fax:
Practice Address - Street 1:1017 E WHITAKER MILL RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27608-2757
Practice Address - Country:US
Practice Address - Phone:919-424-6055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-14
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty