Basic Information
| Provider Information | |||||||||
| NPI: | 1053598920 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FOUNDATION HEALTH SYSTEMS CORP | ||||||||
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| OtherOrganizationName: | EDWIN H. MARTINAT OUTPATIENT COMPREHENSIVE REHABILITATION CTR -KING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 FRONTIS PLAZA BLVD STE 102 | ||||||||
| Address2: | NOVANT MEDICAL GROUP | ||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271035616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362772435 | ||||||||
| FaxNumber: | 3362779275 | ||||||||
| Practice Location | |||||||||
| Address1: | 216 MOORE RD | ||||||||
| Address2: | DBA EDWIN H. MARTINAT OUTPT COMP REHAB CTR -KING | ||||||||
| City: | KING | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270218703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367196165 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2008 | ||||||||
| LastUpdateDate: | 01/23/2008 | ||||||||
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| AuthorizedOfficialLastName: | LINER | ||||||||
| AuthorizedOfficialFirstName: | SALLYE | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXE. VP & CEO & ADMIN | ||||||||
| AuthorizedOfficialTelephone: | 3367182004 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FOUNDATION HEALTH SYSTEMS CORP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 235Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.