Provider Demographics
NPI:1306276217
Name:COMPLEAT REHAB AND SPORTS THERAPY CENTER(SATELLITE BRANCH)OF JORDAN PT
Entity type:Organization
Organization Name:COMPLEAT REHAB AND SPORTS THERAPY CENTER(SATELLITE BRANCH)OF JORDAN PT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALIST SPECIALIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:HUMPHRIES
Authorized Official - Suffix:
Authorized Official - Credentials:CMA
Authorized Official - Phone:704-824-7800
Mailing Address - Street 1:2675 COURT DR
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-1478
Mailing Address - Country:US
Mailing Address - Phone:704-824-7800
Mailing Address - Fax:704-824-2853
Practice Address - Street 1:135 SOUTH EAST STREET
Practice Address - Street 2:
Practice Address - City:MT.IDA
Practice Address - State:AR
Practice Address - Zip Code:71957
Practice Address - Country:US
Practice Address - Phone:870-867-4654
Practice Address - Fax:870-867-2611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-14
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR15614872Medicaid
AR15614872Medicaid