=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851957575
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAMERON MACKENZIE KAPEC PHYSICAL THERAPIST
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2019
-----------------------------------------------------
Last Update Date | 12/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 233 BELL FORK RD STE E
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28540-6471
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-238-2259
-----------------------------------------------------
Fax | 888-209-9322
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6201 GREENLEIGH AVE FL 2
-----------------------------------------------------
City | MIDDLE RIVER
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21220-2004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-933-5412
-----------------------------------------------------
Fax | 410-933-1390
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 9581
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2251S0007X
-----------------------------------------------------
Taxonomy Name | Sports Physical Therapist
-----------------------------------------------------
License Number | 28508
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 28508
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------