Basic Information
| Provider Information | |||||||||
| NPI: | 1427381813 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JORDAN PHYSICAL THERAPY CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HOT SPRINGS SPORTS MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2675 COURT DR | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280541478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048247800 | ||||||||
| FaxNumber: | 7048242853 | ||||||||
| Practice Location | |||||||||
| Address1: | 2278 ALBERT PIKE ROAD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | HOT SPRINGS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 719134157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5017670808 | ||||||||
| FaxNumber: | 5017670832 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2009 | ||||||||
| LastUpdateDate: | 05/19/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HUMPHRIES | ||||||||
| AuthorizedOfficialFirstName: | REBECCA | ||||||||
| AuthorizedOfficialMiddleName: | T. | ||||||||
| AuthorizedOfficialTitleorPosition: | PCC/CREDENTIALING SPECIALIST NC/AR | ||||||||
| AuthorizedOfficialTelephone: | 7048792532 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | JORDAN PHYSICAL THERAPY DBA HOT SPRINGS SPORTS MEDICINE | ||||||||
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| AuthorizedOfficialCredential: | CMA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist | 273Y00000X | Y | Hospital Units | Rehabilitation Unit |
No ID Information.