Provider Demographics
NPI:1669772802
Name:ATHELITE PHYSICAL PERFORMANCE CENTER OF LAKE NORMAN, LLC
Entity type:Organization
Organization Name:ATHELITE PHYSICAL PERFORMANCE CENTER OF LAKE NORMAN, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:BOYLE
Authorized Official - Suffix:
Authorized Official - Credentials:PT; DPT
Authorized Official - Phone:704-241-0889
Mailing Address - Street 1:1385 E GARRISON BLVD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-5127
Mailing Address - Country:US
Mailing Address - Phone:704-768-1013
Mailing Address - Fax:704-264-0711
Practice Address - Street 1:2809 AMITY HILL RD
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-9744
Practice Address - Country:US
Practice Address - Phone:704-768-1013
Practice Address - Fax:704-264-0711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-21
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty