Healthcare Provider Details

I. General information

NPI: 1134894389
Provider Name (Legal Business Name): ARCHITECH SPORTS AND PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2021
Last Update Date: 02/19/2025
Certification Date: 02/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

857 PROMENADE WALK
FORT MILL SC
29708-6992
US

IV. Provider business mailing address

8918 BLAKENEY PROFESSIONAL DR STE 120
CHARLOTTE NC
28277-6692
US

V. Phone/Fax

Practice location:
  • Phone: 803-547-1133
  • Fax:
Mailing address:
  • Phone: 704-900-8960
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KAJA IKOH
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 704-900-8960