Basic Information
| Provider Information | |||||||||
| NPI: | 1770590093 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAGUIRE | ||||||||
| FirstName: | KRISTI | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 BLYTHE BLVD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282035814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043554370 | ||||||||
| FaxNumber: | 7043554231 | ||||||||
| Practice Location | |||||||||
| Address1: | 7825 BALLANTYNE COMMONS PKWY | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282773174 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044467040 | ||||||||
| FaxNumber: | 7047593494 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 7015 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 079UG | 01 | NC | BCBS | OTHER | 182805 | 01 | NC | MEDCOST | OTHER | 7211870 | 05 | NC | MEDICAID |