Provider Demographics
NPI:1790096485
Name:PHYSICAL THERAPY OF THE TRIAD, CORP.
Entity Type:Organization
Organization Name:PHYSICAL THERAPY OF THE TRIAD, CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:LEATHERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:336-391-7892
Mailing Address - Street 1:4628 RIVER VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27265-9295
Mailing Address - Country:US
Mailing Address - Phone:336-391-7892
Mailing Address - Fax:336-665-8446
Practice Address - Street 1:4628 RIVER VALLEY RD
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27265-9295
Practice Address - Country:US
Practice Address - Phone:336-391-7892
Practice Address - Fax:336-665-8446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-28
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8012225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty