Provider Demographics
NPI:1861555278
Name:PHOENIX PHYSICAL THERAPY & SPORTS PERFORMANCE
Entity type:Organization
Organization Name:PHOENIX PHYSICAL THERAPY & SPORTS PERFORMANCE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TATUM
Authorized Official - Middle Name:FOY
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:704-483-0777
Mailing Address - Street 1:290 N HIGHWAY 16
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:NC
Mailing Address - Zip Code:28037-8011
Mailing Address - Country:US
Mailing Address - Phone:704-483-0777
Mailing Address - Fax:704-483-1883
Practice Address - Street 1:290 N HIGHWAY 16
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:NC
Practice Address - Zip Code:28037-8011
Practice Address - Country:US
Practice Address - Phone:704-483-0777
Practice Address - Fax:704-483-1883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9701225100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2348692Medicare PIN
2348692Medicare ID - Type Unspecified