Healthcare Provider Details

I. General information

NPI: 1174968424
Provider Name (Legal Business Name): AT HOME PHYSICAL THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2013
Last Update Date: 12/30/2022
Certification Date: 12/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1163 COOK SCHOOL RD
PILOT MOUNTAIN NC
27041-7606
US

IV. Provider business mailing address

2421 ROLLING TRACKS RD
WILLOW SPRING NC
27592-8301
US

V. Phone/Fax

Practice location:
  • Phone: 919-412-1183
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1174968424
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name: RICHARD SCOTT BETHUNE
Title or Position: OWNER/PT
Credential: DPT
Phone: 919-412-1183