Provider Demographics
NPI:1962449504
Name:SOUTHERN PINES PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:SOUTHERN PINES PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:STOVALL
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:910-692-8269
Mailing Address - Street 1:210 S BENNETT ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHERN PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28387-5402
Mailing Address - Country:US
Mailing Address - Phone:910-692-8269
Mailing Address - Fax:
Practice Address - Street 1:210 S BENNETT ST
Practice Address - Street 2:
Practice Address - City:SOUTHERN PINES
Practice Address - State:NC
Practice Address - Zip Code:28387-5402
Practice Address - Country:US
Practice Address - Phone:910-692-8269
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2089225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC015AGOtherBCBSNC GROUP
NCFH60000150OtherFIRST CAROLINA GROUP
NC2335447Medicare ID - Type UnspecifiedMEDICARE GROUP