Healthcare Provider Details

I. General information

NPI: 1952791832
Provider Name (Legal Business Name): CHRIS G SHEPHERD PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2015
Last Update Date: 01/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 N FODALE AVE
SOUTHPORT NC
28461-3538
US

IV. Provider business mailing address

3563 ANTENNA FARM RD SE
BOLIVIA NC
28422-7601
US

V. Phone/Fax

Practice location:
  • Phone: 910-457-0830
  • Fax:
Mailing address:
  • Phone: 440-787-3087
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA2655
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: