Healthcare Provider Details

I. General information

NPI: 1669772802
Provider Name (Legal Business Name): ATHELITE PHYSICAL PERFORMANCE CENTER OF LAKE NORMAN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2010
Last Update Date: 01/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2809 AMITY HILL RD
STATESVILLE NC
28677-9744
US

IV. Provider business mailing address

1385 E GARRISON BLVD
GASTONIA NC
28054-5127
US

V. Phone/Fax

Practice location:
  • Phone: 704-768-1013
  • Fax: 704-264-0711
Mailing address:
  • Phone: 704-768-1013
  • Fax: 704-264-0711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. BRIAN J BOYLE
Title or Position: CEO
Credential: P.T.; D.P.T.
Phone: 704-241-0889