Provider Demographics
NPI:1730698556
Name:CRYOWELL PHYSICAL THERAPY
Entity type:Organization
Organization Name:CRYOWELL PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DWIGHT
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:PEEPLES
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:404-320-0981
Mailing Address - Street 1:3842 MOURNING DOVE DR
Mailing Address - Street 2:
Mailing Address - City:WEDDINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28104-8636
Mailing Address - Country:US
Mailing Address - Phone:404-308-0981
Mailing Address - Fax:
Practice Address - Street 1:37 BRENDAN WAY
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3514
Practice Address - Country:US
Practice Address - Phone:687-866-3646
Practice Address - Fax:888-651-5324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-25
Last Update Date:2017-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8180225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH3404Medicaid