Basic Information
| Provider Information | |||||||||
| NPI: | 1861934010 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSICAL THERAPY CENTER TWO, LLC | ||||||||
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| OtherOrganizationName: | PHYSICAL THERAPY CENTER, LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1730 DICKERSON BLVD | ||||||||
| Address2: | SUITE D | ||||||||
| City: | MONROE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281102885 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042836700 | ||||||||
| FaxNumber: | 7042836713 | ||||||||
| Practice Location | |||||||||
| Address1: | 2400 SOUTH BLVD. | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042836700 | ||||||||
| FaxNumber: | 7042836713 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2016 | ||||||||
| LastUpdateDate: | 11/04/2016 | ||||||||
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| AuthorizedOfficialLastName: | KOOS | ||||||||
| AuthorizedOfficialFirstName: | TODD | ||||||||
| AuthorizedOfficialMiddleName: | DOUGLAS | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7045029205 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | P9417 | NC | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.