Healthcare Provider Details

I. General information

NPI: 1891052601
Provider Name (Legal Business Name): PHYSIOFOCUS ORTHOPEDIC AND SPORTS THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2012
Last Update Date: 07/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7239 PINEVILLE MATTHEWS RD SUITE 400
CHARLOTTE NC
28226-6153
US

IV. Provider business mailing address

4006 CAMROSE CROSSING LN
MATTHEWS NC
28104-6831
US

V. Phone/Fax

Practice location:
  • Phone: 980-224-7958
  • Fax: 980-224-7973
Mailing address:
  • Phone: 224-392-4872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number11158
License Number StateNC

VIII. Authorized Official

Name: MR. THOMAS CUSACK
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 224-392-4872