Basic Information
| Provider Information | |||||||||
| NPI: | 1467673632 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LIM | ||||||||
| FirstName: | MARLON | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7594 | ||||||||
| Address2: | |||||||||
| City: | ROCKY MOUNT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278040594 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2524430808 | ||||||||
| FaxNumber: | 2524519032 | ||||||||
| Practice Location | |||||||||
| Address1: | 1223 JULIAN R ALLSBROOK HWY | ||||||||
| Address2: | |||||||||
| City: | ROANOKE RAPIDS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278705126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2525371215 | ||||||||
| FaxNumber: | 2525371816 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2007 | ||||||||
| LastUpdateDate: | 04/16/2009 | ||||||||
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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 | 8735 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 2504211 | 01 | NC | MEDICARE - CPTA | OTHER | 2504211A | 01 | NC | MEDICARE - WOSNC | OTHER | 7212481 | 05 | NC | MEDICAID | 078UW | 01 | BCBS | OTHER |