Provider Demographics
NPI:1013451301
Name:PHOENIX PHYSICAL THERAPY AND SPORTS PERFORMANCE -LAKE NORMAN
Entity Type:Organization
Organization Name:PHOENIX PHYSICAL THERAPY AND SPORTS PERFORMANCE -LAKE NORMAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:D
Authorized Official - Last Name:VAUGHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:704-483-0777
Mailing Address - Street 1:290 N HIGHWAY 16
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:NC
Mailing Address - Zip Code:28037-8011
Mailing Address - Country:US
Mailing Address - Phone:704-483-0777
Mailing Address - Fax:704-483-1883
Practice Address - Street 1:7825 NC HIGHWAY 150 E STE 6
Practice Address - Street 2:
Practice Address - City:TERRELL
Practice Address - State:NC
Practice Address - Zip Code:28682-8703
Practice Address - Country:US
Practice Address - Phone:704-483-0777
Practice Address - Fax:704-483-1883
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHOENIX PHYSICAL THERAPY AND SPORTS PERFORMANCE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-12-06
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP148072251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty