Provider Demographics
NPI:1184806283
Name:PROFESSIONAL PHYSICAL THERAPY & REHABILITATION, LLC
Entity type:Organization
Organization Name:PROFESSIONAL PHYSICAL THERAPY & REHABILITATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANE
Authorized Official - Middle Name:A
Authorized Official - Last Name:PERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:910-438-9701
Mailing Address - Street 1:825 GUM BRANCH RD
Mailing Address - Street 2:SUITE 127
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540-6298
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:825 GUM BRANCH RD
Practice Address - Street 2:SUITE 127
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28540-6298
Practice Address - Country:US
Practice Address - Phone:910-438-9701
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-29
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9366261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
803352Medicare PIN