Basic Information
| Provider Information | |||||||||
| NPI: | 1689746620 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRIDLEY | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | I | ||||||||
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| Credential: | MPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1317 N BRIGHTLEAF BLVD STE A | ||||||||
| Address2: | |||||||||
| City: | SMITHFIELD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275777267 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193005040 | ||||||||
| FaxNumber: | 9194380893 | ||||||||
| Practice Location | |||||||||
| Address1: | 1317 N BRIGHTLEAF BLVD STE A | ||||||||
| Address2: | |||||||||
| City: | SMITHFIELD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275777267 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193005040 | ||||||||
| FaxNumber: | 9194380893 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2006 | ||||||||
| LastUpdateDate: | 02/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | P13553 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
ID Information
| ID | Type | State | Issuer | Description | 50652901 | 05 | HI | MEDICAID | 0000235085 | 01 | HI | HMSA | OTHER |