Healthcare Provider Details

I. General information

NPI: 1265772636
Provider Name (Legal Business Name): TRIANGLE ELECTRODIAGNOSTICS & PHYSICAL THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2013
Last Update Date: 03/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4208 OAKTHORNE WAY
RALEIGH NC
27613-5922
US

IV. Provider business mailing address

4208 OAKTHORNE WAY
RALEIGH NC
27613-5922
US

V. Phone/Fax

Practice location:
  • Phone: 919-624-2358
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251E1300X
TaxonomyClinical Electrophysiology Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL A VITA JR.
Title or Position: OWNER
Credential:
Phone: 919-624-2358