Provider Demographics
NPI:1851307441
Name:TANTILLA, BRIAN C (PT)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:C
Last Name:TANTILLA
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 1:1107 NEW POINTE BLVD SUITE B-6
Mailing Address - Street 2:CORE THERAPY SERVICES
Mailing Address - City:LELAND
Mailing Address - State:NC
Mailing Address - Zip Code:28451-4217
Mailing Address - Country:US
Mailing Address - Phone:910-399-1922
Mailing Address - Fax:866-844-3505
Practice Address - Street 1:1107 NEW POINTE BLVD SUITE B-6
Practice Address - Street 2:CORE THERAPY SERVICES
Practice Address - City:LELAND
Practice Address - State:NC
Practice Address - Zip Code:28451-4217
Practice Address - Country:US
Practice Address - Phone:910-399-1922
Practice Address - Fax:866-844-3505
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10015225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC079NCOtherBCBSNC PROVIDER NUMBER
NC079NCOtherBCBSNC PROVIDER NUMBER