Provider Demographics
NPI:1457764623
Name:PRUE PHYSICAL THERAPY AND SPORTS PERFORMANCE LLC
Entity Type:Organization
Organization Name:PRUE PHYSICAL THERAPY AND SPORTS PERFORMANCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PRUE
Authorized Official - Suffix:
Authorized Official - Credentials:PT,DPT,CSCS
Authorized Official - Phone:860-208-5382
Mailing Address - Street 1:1020 SOUTHHILL DR STE 140
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27513-8629
Mailing Address - Country:US
Mailing Address - Phone:919-678-8828
Mailing Address - Fax:
Practice Address - Street 1:1020 SOUTHHILL DR STE 140
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27513-8629
Practice Address - Country:US
Practice Address - Phone:919-678-8828
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-05
Last Update Date:2014-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14896261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy