=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780049429
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PTA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/23/2015
-----------------------------------------------------
Last Update Date | 12/23/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1900 SHELDON ROAD
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-609-1832
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1900 SHELDON RD
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27405-1645
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PTA
-----------------------------------------------------
Name | HRACHEL AYUN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 336-609-1832
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320700000X
-----------------------------------------------------
Taxonomy Name | Physical Disabilities Residential Treatment Facility
-----------------------------------------------------
License Number | 2251500000X
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------