Basic Information
| Provider Information | |||||||||
| NPI: | 1588623847 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HAVELOCK PEAK PERFORMANCE SPORTS & PHYSICAL THERAPY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 13609 | ||||||||
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| City: | NEW BERN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285613609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2526369800 | ||||||||
| FaxNumber: | 2526361945 | ||||||||
| Practice Location | |||||||||
| Address1: | 1202 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HAVELOCK | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285322405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2524474005 | ||||||||
| FaxNumber: | 2524474001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 04/30/2018 | ||||||||
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| AuthorizedOfficialLastName: | LAURENT | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
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| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 6163565011 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | N/A | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 7212000 | 05 | NC | MEDICAID | 017XX | 01 | NC | BCBSNC | OTHER |