Basic Information
| Provider Information | |||||||||
| NPI: | 1598177214 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED PHYSICAL THERAPY OF CLINTON LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 317 NORTH BLVD | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102494040 | ||||||||
| FaxNumber: | 9102499250 | ||||||||
| Practice Location | |||||||||
| Address1: | 317 NORTH BLVD | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283281911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102494040 | ||||||||
| FaxNumber: | 9102499250 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2014 | ||||||||
| LastUpdateDate: | 10/28/2015 | ||||||||
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| AuthorizedOfficialLastName: | SKULAVIK | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9193005040 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | 10731 | NC | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | 1598177214 | 05 | NC | MEDICAID |