Basic Information
| Provider Information | |||||||||
| NPI: | 1093775322 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | DOUGLAS | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1393 CELANESE RD | ||||||||
| Address2: | |||||||||
| City: | ROCK HILL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297321722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033293103 | ||||||||
| FaxNumber: | 8033252232 | ||||||||
| Practice Location | |||||||||
| Address1: | 1393 CELANESE RD | ||||||||
| Address2: | |||||||||
| City: | ROCK HILL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297321722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033293103 | ||||||||
| FaxNumber: | 8033252232 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 03/04/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 3834 | SC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 6620 | NC | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | E1570 | 01 | MEDCOST | OTHER | 0788C | 01 | NC | BLUE CROSS BLUE SHIELD NC | OTHER |