=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982423661
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REBOUND HEALTH & PERFORMANCE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2024
-----------------------------------------------------
Last Update Date | 10/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2819 BRIAR RIDGE DR
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28270-0711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-618-2037
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2819 BRIAR RIDGE DR
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28270-0711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-618-2037
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/FOUNDER
-----------------------------------------------------
Name | DR. JONATHON GARDNER
-----------------------------------------------------
Credential | PT, DPT, SCS, CSCS
-----------------------------------------------------
Telephone | 843-618-2037
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------