Provider Demographics
NPI:1285679373
Name:PHYSICAL THERAPY CLINIC INC
Entity type:Organization
Organization Name:PHYSICAL THERAPY CLINIC INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER/PT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LEANNE
Authorized Official - Middle Name:LYON
Authorized Official - Last Name:BURNS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:910-577-3355
Mailing Address - Street 1:26 OFFICE PARK DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-7325
Mailing Address - Country:US
Mailing Address - Phone:910-577-3355
Mailing Address - Fax:910-577-4556
Practice Address - Street 1:26 OFFICE PARK DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546
Practice Address - Country:US
Practice Address - Phone:910-577-3355
Practice Address - Fax:910-577-4556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4047225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0229MOtherBLUE CROSS & BLUE SHIELD
NC153455500OtherFED W/C OWCP
NC70592OtherMEDCOST
=========OtherTRICARE
NC2329608Medicare PIN
NC2329608Medicare PIN
NC153455500OtherFED W/C OWCP