=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053641670
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEW MILLENNIUM THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2010
-----------------------------------------------------
Last Update Date | 01/04/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8213 ESCAFLOWNE AVE
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28216-2265
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-906-3585
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8213 ESCAFLOWNE AVE
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28216-2265
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-906-3585
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. TIMOTHY LAVAR FREEMAN
-----------------------------------------------------
Credential | OTR/L
-----------------------------------------------------
Telephone | 704-906-3585
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Clinic/Center
-----------------------------------------------------
License Number | 5090
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------