=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932382041
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FLAT ROCK PHYSICAL THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2007
-----------------------------------------------------
Last Update Date | 03/05/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 615 KANUGA RD
-----------------------------------------------------
City | HENDERSONVLLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28739-5227
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-696-9411
-----------------------------------------------------
Fax | 828-696-8202
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 615 KANUGA RD
-----------------------------------------------------
City | HENDERSONVLLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28739-5227
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-696-9411
-----------------------------------------------------
Fax | 828-696-8202
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. EDWARD MAYNOR
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 828-696-9411
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251X0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Physical Therapist
-----------------------------------------------------
License Number | 8415
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------