Provider Demographics
NPI:1891052601
Name:PHYSIOFOCUS ORTHOPEDIC AND SPORTS THERAPY LLC
Entity Type:Organization
Organization Name:PHYSIOFOCUS ORTHOPEDIC AND SPORTS THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:CUSACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:224-392-4872
Mailing Address - Street 1:4006 CAMROSE CROSSING LN
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28104-6831
Mailing Address - Country:US
Mailing Address - Phone:224-392-4872
Mailing Address - Fax:
Practice Address - Street 1:7239 PINEVILLE MATTHEWS RD
Practice Address - Street 2:SUITE 400
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-6153
Practice Address - Country:US
Practice Address - Phone:980-224-7958
Practice Address - Fax:980-224-7973
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-18
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11158261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy