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General NPI Number Information
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NPI Number | 1164482402
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Entity Type | Organization
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Legal Business Name | JACKSONVILLE PEAK PERFORMANCE SPORTS & PHYSICAL THERAPY, L.L.C.
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Dates
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Enumeration Date | 03/23/2006
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Last Update Date | 04/30/2018
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Provider Practice Location Address
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Address Line | 122 BRANCHWOOD SHOPPING CTR
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City | JACKSONVILLE
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State | NC
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Zip | 28546-5800
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Country | US
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Telephone | 910-938-7555
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Fax | 910-938-7544
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Provider Business Mailing Address
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Address Line | 607 DEWEY AVE NW SUITE 300
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City | GRAND RAPIDS
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State | MI
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Zip | 49504-7335
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Country | US
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Telephone | 616-356-5000
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Fax | 616-356-5001
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Authorized Official
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Title or Position | AUTHORIZED OFFICIAL
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Name | JOSEPH LAURENT
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Credential |
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Telephone | 616-356-5011
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State |
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