MEDICARE: FULL MOTION PHYSICAL THERAPY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2000X	Physical Therapy Clinic/Center	11833	NC

General Provider Information

NPI Number	:	1821396557
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FULL MOTION PHYSICAL THERAPY, LLC

Provider Business Mailing Address
First Line	:	5113 PIPER STATION DR
Second Line	:	SUITE 202
City	:	CHARLOTTE
State	:	NC
Zip	:	28277-6689
Country	:	US
Telephone Number	:	980-224-8191
Fax Number	:	980-224-8194

Provider Business Practice Location Address
First Line	:	5113 PIPER STATION DR
Second Line	:	SUITE 202
City	:	CHARLOTTE
State	:	NC
Zip	:	28277-6689
Country	:	US
Telephone Number	:	980-224-8191
Fax Number	:	980-224-8194

Authorized Official
Title or Position	:	PHYSICAL THERAPIST/CLINIC DIRECTOR
Name	:	STACI L MILLER
Credential	:	P.T.
Telephone Number	:	980-224-8191

Provider Enumeration Date	:	03/03/2011
Last Update Date	:	04/12/2011

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