=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083099394
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHILDREN'S PLACE PEDIATRIC THERAPIES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2015
-----------------------------------------------------
Last Update Date | 07/28/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5760 BUNCH RD
-----------------------------------------------------
City | OAK RIDGE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27310-9742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-382-9797
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5760 BUNCH RD
-----------------------------------------------------
City | OAK RIDGE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27310-9742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-382-9797
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MEMBER
-----------------------------------------------------
Name | DR. DAMITA WATKINS-AMICK
-----------------------------------------------------
Credential | MPT, DPT
-----------------------------------------------------
Telephone | 336-382-9797
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Clinic/Center
-----------------------------------------------------
License Number | P13476
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------