Basic Information
| Provider Information | |||||||||
| NPI: | 1972045193 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BENCHMARK PHYSICAL THERAPY OF NC, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | BENCHMARK PT - HIGH POINT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 6397 LEE HWY STE 300 | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374212564 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232387217 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3935 BRIAN JORDAN PL | ||||||||
| Address2: | STE 119 | ||||||||
| City: | HIGH POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272658036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368850440 | ||||||||
| FaxNumber: | 3368850442 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2016 | ||||||||
| LastUpdateDate: | 09/01/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JOHANNESON | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP REVENUE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 4232387217 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 235Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.