Basic Information
| Provider Information | |||||||||
| NPI: | 1649619156 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMPLEAT REHAB AND SPORTS THERAPY, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COMP REHAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 135 SOUTH EAST STREET | ||||||||
| Address2: | |||||||||
| City: | MT IDA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 71957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708674654 | ||||||||
| FaxNumber: | 8708672611 | ||||||||
| Practice Location | |||||||||
| Address1: | 2675 COURT DR | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280541478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048247800 | ||||||||
| FaxNumber: | 7048247898 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2013 | ||||||||
| LastUpdateDate: | 06/18/2013 | ||||||||
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| AuthorizedOfficialLastName: | HUMPHRIES | ||||||||
| AuthorizedOfficialFirstName: | REBECCA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PATIENT CARE COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 7048792532 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CMA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | 156148742 | 05 | AR | MEDICAID |