=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215596978
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FUNDAMENTAL PHYSICAL THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2019
-----------------------------------------------------
Last Update Date | 06/06/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9517 SADDLE RUN TRL
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28269-0383
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-509-4141
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9517 SADDLE RUN TRL
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28269-0383
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-509-4141
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST
-----------------------------------------------------
Name | MRS. DARLENE JEAN RYAN
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 704-509-4141
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------