Provider Demographics
NPI:1962603266
Name:GREENVILLE PEAK PERFORMANCE SPORTS & PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:GREENVILLE PEAK PERFORMANCE SPORTS & PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:LAURENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-356-5011
Mailing Address - Street 1:607 DEWEY AVE NW
Mailing Address - Street 2:SUITE 300
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-7335
Mailing Address - Country:US
Mailing Address - Phone:616-356-5000
Mailing Address - Fax:616-356-5001
Practice Address - Street 1:740 W FIRE TOWER RD
Practice Address - Street 2:SUITE 113
Practice Address - City:WINTERVILLE
Practice Address - State:NC
Practice Address - Zip Code:28590-8411
Practice Address - Country:US
Practice Address - Phone:252-636-9800
Practice Address - Fax:252-636-1945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2018-04-30
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
NC019E8OtherBCBSNC
NC7200527Medicaid
NC019E8OtherBCBSNC