Healthcare Provider Details

I. General information

NPI: 1972820199
Provider Name (Legal Business Name): THEODORE J BALLARD DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2010
Last Update Date: 01/05/2024
Certification Date: 01/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

WOMACK 2817 ROCK MERRITT AVE
FAYETTEVILLE NC
28307
US

IV. Provider business mailing address

WOMACK 2817 ROCK MERRITT AVE
FAYETTEVILLE NC
28307
US

V. Phone/Fax

Practice location:
  • Phone: 910-643-1472
  • Fax:
Mailing address:
  • Phone: 910-643-1472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number14641
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number23236
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: