Basic Information
| Provider Information | |||||||||
| NPI: | 1396306395 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HINES | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | TRACY | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 122 BRANCHWOOD SHOPPING CTR | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285465800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9109387555 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 122 BRANCHWOOD SHOPPING CTR | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285465800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9109387555 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2019 | ||||||||
| LastUpdateDate: | 06/21/2019 | ||||||||
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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 | 4644 | SC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | NONE | 01 | NONE | OTHER |