Healthcare Provider Details

I. General information

NPI: 1700458650
Provider Name (Legal Business Name): MOORESVILLE SPORTS & PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2021
Last Update Date: 07/12/2021
Certification Date: 07/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

478 WILLIAMSON RD STE E
MOORESVILLE NC
28117-9109
US

IV. Provider business mailing address

17217 ROYAL COURT DR
DAVIDSON NC
28036-7843
US

V. Phone/Fax

Practice location:
  • Phone: 704-696-8223
  • Fax: 704-696-8231
Mailing address:
  • Phone: 704-719-7348
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: EDWARD HELLER
Title or Position: OWNER/PHYSICAL THERAPIST
Credential: MSPT, ATC, CMTPT
Phone: 704-719-7348