Healthcare Provider Details

I. General information

NPI: 1104279520
Provider Name (Legal Business Name): PROVIDENCE PHYSICAL THERAPY & PERFORMANCE, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2016
Last Update Date: 02/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 LIVE OAK ST
TABOR CITY NC
28463-2042
US

IV. Provider business mailing address

PO BOX 219
TABOR CITY NC
28463-0219
US

V. Phone/Fax

Practice location:
  • Phone: 252-916-9949
  • Fax:
Mailing address:
  • Phone: 910-377-3146
  • Fax: 910-377-3277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number10244
License Number StateNC

VIII. Authorized Official

Name: DR. KEVIN BRIAN BULLARD
Title or Position: PHYSICAL THERAPIST/OWNER/MANAGER
Credential: DPT
Phone: 252-916-9949