Healthcare Provider Details

I. General information

NPI: 1003400235
Provider Name (Legal Business Name): THERON LOCKE DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2021
Last Update Date: 02/28/2021
Certification Date: 02/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 DOTHAN RD
ABBEVILLE AL
36310-2800
US

IV. Provider business mailing address

601 WHATLEY DR APT H7007
DOTHAN AL
36303-2475
US

V. Phone/Fax

Practice location:
  • Phone: 334-585-2241
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: