Healthcare Provider Details

I. General information

NPI: 1508736158
Provider Name (Legal Business Name): MR. TIMOTHY PATRICK O'HARE II
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2025
Last Update Date: 11/10/2025
Certification Date: 11/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3113 LEDGEWOOD DR
APEX NC
27539-3013
US

IV. Provider business mailing address

208 TRAILVIEW DR
CARY NC
27513-1621
US

V. Phone/Fax

Practice location:
  • Phone: 631-681-4821
  • Fax:
Mailing address:
  • Phone: 631-681-4821
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number22036
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: