Healthcare Provider Details

I. General information

NPI: 1447620729
Provider Name (Legal Business Name): ARCHITECH SPORTS AND PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2015
Last Update Date: 03/03/2025
Certification Date: 03/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13333 DORMAN RD
PINEVILLE NC
28213-8920
US

IV. Provider business mailing address

13333 DORMAN RD
PINEVILLE NC
28134-9336
US

V. Phone/Fax

Practice location:
  • Phone: 704-716-1024
  • Fax:
Mailing address:
  • Phone: 704-716-1024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number2487
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: KAJA IKOH
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 704-900-8960