Provider Demographics
NPI:1699711507
Name:CAROLINA PHYSICAL REHABILITATION SERVICES, INC.
Entity type:Organization
Organization Name:CAROLINA PHYSICAL REHABILITATION SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHADE
Authorized Official - Middle Name:F
Authorized Official - Last Name:BADA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-624-0346
Mailing Address - Street 1:507 JONES ST
Mailing Address - Street 2:PO BOX 237
Mailing Address - City:MARSHVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28103-1231
Mailing Address - Country:US
Mailing Address - Phone:704-624-0346
Mailing Address - Fax:704-624-0356
Practice Address - Street 1:507 JONES ST
Practice Address - Street 2:
Practice Address - City:MARSHVILLE
Practice Address - State:NC
Practice Address - Zip Code:28103-1231
Practice Address - Country:US
Practice Address - Phone:704-624-0346
Practice Address - Fax:704-624-0356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7131225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7211726Medicaid
NC7211726Medicaid
NCDD4478Medicare ID - Type UnspecifiedRAILROAD MEDICARE