=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386121606
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAROLINA PHYSICAL THERAPY ASSOCIATES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2018
-----------------------------------------------------
Last Update Date | 07/20/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13200 STRICKLAND RD STE 134
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27613-5214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-557-3017
-----------------------------------------------------
Fax | 919-557-3748
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1110 SHAWNEE RD
-----------------------------------------------------
City | LIMA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45805-3529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-221-6720
-----------------------------------------------------
Fax | 419-222-0507
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE VICE PRESIDENT
-----------------------------------------------------
Name | MR. BRAD C ROUSH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 419-221-6712
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------