Provider Demographics
NPI:1316996317
Name:WAKE FOREST PHYSICAL THERAPY
Entity type:Organization
Organization Name:WAKE FOREST PHYSICAL THERAPY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRISSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-570-7080
Mailing Address - Street 1:843 WAKE FOREST BUSINESS PARK
Mailing Address - Street 2:SUITE 110
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-6577
Mailing Address - Country:US
Mailing Address - Phone:919-570-7080
Mailing Address - Fax:919-570-7081
Practice Address - Street 1:843 WAKE FOREST BUSINESS PARK
Practice Address - Street 2:SUITE 110
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-6577
Practice Address - Country:US
Practice Address - Phone:919-570-7080
Practice Address - Fax:919-570-7081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1112QOtherBLUE CROSS BLUE SHIELD
NC101957600OtherDEPT. LABOR WORKERS COMP
NCC6034OtherMEDCOST
NC7659542OtherAETNA
NC1112QOtherBLUE CROSS BLUE SHIELD