Provider Demographics
NPI:1861580102
Name:PORT CITY PHYSICAL THERAPY, INC.
Entity type:Organization
Organization Name:PORT CITY PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:ROYCE
Authorized Official - Last Name:JARBOE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:910-763-7674
Mailing Address - Street 1:321 N FRONT ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-3908
Mailing Address - Country:US
Mailing Address - Phone:910-763-7674
Mailing Address - Fax:910-763-8533
Practice Address - Street 1:321 N FRONT ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-3908
Practice Address - Country:US
Practice Address - Phone:910-763-7674
Practice Address - Fax:910-763-8533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1796222Z00000X
NC2549225100000X, 2251X0800X
NC173225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7200115Medicaid
NC7210534Medicaid
NC173OtherNC MASSAGE THERAPIST LIC#
NC1821190075OtherINDIVIDUAL NPI NUMBER
NC2549OtherNC PT LICENSE NUMBER
NC2549OtherNC PT LICENSE NUMBER
NCS99836Medicare UPIN