Basic Information
| Provider Information | |||||||||
| NPI: | 1497739783 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COLVILLE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | LYTLE | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4601 PARK RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282093239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043232000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9848 NORTH TRYON STREET | ||||||||
| Address2: | STE 200 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043232000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2005 | ||||||||
| LastUpdateDate: | 07/19/2010 | ||||||||
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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 | 2251X0800X | 10080 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
No ID Information.