Provider Demographics
NPI:1649619156
Name:COMPLEAT REHAB AND SPORTS THERAPY, LLC
Entity type:Organization
Organization Name:COMPLEAT REHAB AND SPORTS THERAPY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PATIENT CARE COORDINATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:HUMPHRIES
Authorized Official - Suffix:
Authorized Official - Credentials:CMA
Authorized Official - Phone:704-879-2532
Mailing Address - Street 1:135 SOUTH EAST STREET
Mailing Address - Street 2:
Mailing Address - City:MT IDA
Mailing Address - State:AR
Mailing Address - Zip Code:71957
Mailing Address - Country:US
Mailing Address - Phone:870-867-4654
Mailing Address - Fax:870-867-2611
Practice Address - Street 1:2675 COURT DR
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-1478
Practice Address - Country:US
Practice Address - Phone:704-824-7800
Practice Address - Fax:704-824-7898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-18
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR156148742Medicaid
AR046571Medicare PIN