Healthcare Provider Details

I. General information

NPI: 1518637305
Provider Name (Legal Business Name): THERASPACE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2021
Last Update Date: 09/14/2021
Certification Date: 09/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 CYPRESS DRIVE
SPRING LAKE NC
28390
US

IV. Provider business mailing address

125 CYPRESS DRIVE
SPRING LAKE NC
28390
US

V. Phone/Fax

Practice location:
  • Phone: 305-794-7185
  • Fax:
Mailing address:
  • Phone: 305-794-7185
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MR. NELSON LOPEZ
Title or Position: PRESIDENT/ PHYSICAL THERAPIST
Credential: DOCTOR
Phone: 786-553-1606