Healthcare Provider Details

I. General information

NPI: 1225035736
Provider Name (Legal Business Name): BRIDDELL PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 08/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1666 WIMBLEDON DR APT 204
GREENVILLE NC
27858-5392
US

IV. Provider business mailing address

PO BOX 1651
GREENVILLE NC
27835-1651
US

V. Phone/Fax

Practice location:
  • Phone: 410-251-4467
  • Fax:
Mailing address:
  • Phone: 410-251-4467
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number5297
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number17958
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberJ1-0001697
License Number StateDE
# 4
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number11098
License Number StateNC

VIII. Authorized Official

Name: DR. DERRICK ANTONIO BRIDDELL
Title or Position: OWNER/PHYSICAL THERAPIST
Credential: PT, DSC, MS, SCS
Phone: 410-251-4467