Provider Demographics
NPI:1518366566
Name:DALTON PEDIATRIC THERAPY, LLC
Entity type:Organization
Organization Name:DALTON PEDIATRIC THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:DALTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-694-4720
Mailing Address - Street 1:45 OAK PARK DR
Mailing Address - Street 2:LOOKING GLASS SUITE
Mailing Address - City:BREVARD
Mailing Address - State:NC
Mailing Address - Zip Code:28712-3183
Mailing Address - Country:US
Mailing Address - Phone:828-694-4720
Mailing Address - Fax:
Practice Address - Street 1:45 OAK PARK DR
Practice Address - Street 2:LOOKING GLASS SUITE
Practice Address - City:BREVARD
Practice Address - State:NC
Practice Address - Zip Code:28712-3183
Practice Address - Country:US
Practice Address - Phone:828-694-4720
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-15
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14791225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1083708895Medicaid