Provider Demographics
NPI:1740069533
Name:INNER COASTAL PLAIN - PT, LLC
Entity type:Organization
Organization Name:INNER COASTAL PLAIN - PT, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GENNYTZA
Authorized Official - Middle Name:
Authorized Official - Last Name:FURNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-797-2148
Mailing Address - Street 1:150 FRANCAM DR STE 124
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28311-4500
Mailing Address - Country:US
Mailing Address - Phone:910-797-2148
Mailing Address - Fax:
Practice Address - Street 1:150 FRANCAM DR STE 124
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28311-4500
Practice Address - Country:US
Practice Address - Phone:910-797-2148
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-21
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty