Provider Demographics
NPI:1821294299
Name:CAROLINA PEDIATRIC REHABILITATION SERVICES, INC.
Entity Type:Organization
Organization Name:CAROLINA PEDIATRIC REHABILITATION SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:KANE-MAXWELL
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICAL THERAPIST
Authorized Official - Phone:910-520-0202
Mailing Address - Street 1:405 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-5001
Mailing Address - Country:US
Mailing Address - Phone:910-520-0202
Mailing Address - Fax:910-254-3566
Practice Address - Street 1:405 S 2ND ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-5001
Practice Address - Country:US
Practice Address - Phone:910-520-0202
Practice Address - Fax:910-254-3566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-22
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4511225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7210741Medicaid