MEDICARE: CAROLINA BEACH PHYSICAL THERAPY

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

General Provider Information

NPI Number	:	1891216362
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAROLINA BEACH PHYSICAL THERAPY

Provider Business Mailing Address
First Line	:	1300 BRIDGE BARRIER RD
Second Line	:	BLDG 3
City	:	CAROLINA BEACH
State	:	NC
Zip	:	28428-4808
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1300 BRIDGE BARRIER RD STE 3
Second Line	:
City	:	CAROLINA BEACH
State	:	NC
Zip	:	28428-3939
Country	:	US
Telephone Number	:	910-309-8141
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LAURIE JEAN ETHERINGTON
Credential	:	PT
Telephone Number	:	910-309-8141

Provider Enumeration Date	:	07/05/2017
Last Update Date	:	08/01/2017

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