MEDICARE: VICTOR RASHAD FAIRLEY-FREEMAN PT, DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	P21989	NC

General Provider Information

NPI Number	:	1992407811
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VICTOR RASHAD FAIRLEY-FREEMAN PT, DPT

Provider Business Mailing Address
First Line	:	2675 COURT DR
Second Line	:
City	:	GASTONIA
State	:	NC
Zip	:	28054-1478
Country	:	US
Telephone Number	:	704-824-7800
Fax Number	:	704-824-2822

Provider Business Practice Location Address
First Line	:	9550 ROCKY RIVER RD STE 201
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28215-9526
Country	:	US
Telephone Number	:	980-255-3610
Fax Number	:	704-526-0680

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/22/2023
Last Update Date	:	03/22/2023

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