Provider Demographics
NPI:1285261792
Name:LERRO JR, JOHN RALPH (PTA)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:RALPH
Last Name:LERRO JR
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 CALLA LILLY LN
Mailing Address - Street 2:
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-2473
Mailing Address - Country:US
Mailing Address - Phone:336-223-3706
Mailing Address - Fax:
Practice Address - Street 1:142 BERMUDA VILLAGE DR
Practice Address - Street 2:
Practice Address - City:ADVANCE
Practice Address - State:NC
Practice Address - Zip Code:27006-7867
Practice Address - Country:US
Practice Address - Phone:336-588-1016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-25
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3114225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant