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General NPI Number Information
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NPI Number | 1154730992
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Entity Type | Individual
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Provider Name | NILES FLEET DPT, PT, SCS, ATC
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Gender | Male
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Dates
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Enumeration Date | 08/06/2014
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Last Update Date | 08/06/2014
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Provider Practice Location Address
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Address Line | WINGATE RD. REYNOLDS GYMNASIUM ROOM 106
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City | WINSTON SALEM
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State | NC
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Zip | 27106
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Country | US
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Telephone | 336-758-5620
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 7329
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City | WINSTON SALEM
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State | NC
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Zip | 27109-6231
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2251S0007X
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Taxonomy Name | Sports Physical Therapist
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License Number | P13893
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | LAT-2086
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License Number State | NC
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