Healthcare Provider Details

I. General information

NPI: 1770577397
Provider Name (Legal Business Name): JOHN RAYMOND MEDINA P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 04/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 W US HIGHWAY 19E
BURNSVILLE NC
28714-8602
US

IV. Provider business mailing address

PO BOX 1358
BURNSVILLE NC
28714-1358
US

V. Phone/Fax

Practice location:
  • Phone: 828-682-1500
  • Fax: 828-682-1505
Mailing address:
  • Phone: 828-682-1500
  • Fax: 828-682-1505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number4787
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: