Provider Demographics
NPI:1902392418
Name:CAROLINA PRIME PHYSICAL THERAPY
Entity Type:Organization
Organization Name:CAROLINA PRIME PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:FORREST
Authorized Official - Suffix:
Authorized Official - Credentials:PT COMT
Authorized Official - Phone:336-990-1028
Mailing Address - Street 1:343 FOREST GLEN LN
Mailing Address - Street 2:
Mailing Address - City:WILKESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28697-7000
Mailing Address - Country:US
Mailing Address - Phone:336-990-1028
Mailing Address - Fax:
Practice Address - Street 1:200 W PARK CIR STE A
Practice Address - Street 2:
Practice Address - City:NORTH WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28659-3583
Practice Address - Country:US
Practice Address - Phone:336-818-2700
Practice Address - Fax:336-450-1700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-09
Last Update Date:2023-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208100000X
NCP10047261QP2000X, 261QR0400X
NC8609261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1366689374Medicaid
NC1770944886Medicaid