NPI |
1336908011 |
Code indicating whether the provider is operating as a sole proprietor. Codes are: Y = Yes; N = No |
Entity Type Code |
2 |
Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual
human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO). |
Employer Identification Number EIN |
|
The last name of the provider. If the provider is an individual, this is the legal name. |
Provider Organization Name Legal Business Name |
SMPT PHYSICAL THERAPY & WELLNESS LLC |
The first name of the provider, if the provider
is an individual. |
Provider First Line Business Practice Location Address |
865 VINTAGE DR |
The first line location address of the provider
being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box. |
Provider Business Practice Location Address City Name |
MOORESVILLE |
The city name in the location address of the provider being identified. |
Provider Business Practice Location Address State Name |
NC |
The State code in the location of the provider
being identified. |
Provider Business Practice Location Address Postal Code |
281154701 |
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. |
Provider Business Practice Location Address Country Code If outside U S |
US |
The country code in the location address of the provider being identified. |
Provider Business Practice Location Address Telephone Number |
7049415677 |
The telephone number associated with the location address of the provider being identified. |
Provider Enumeration Date |
3/15/2024 |
The fax number associated with the location
address of the provider being identified. |
Last Update Date |
4/3/2024 |
The date the provider was assigned a unique identifier (assigned an NPI). |
Authorized Official Last Name |
MINICK |
The date that a record was last updated or changed. |
Authorized Official First Name |
SHAWN |
The code designating the provider’s gender if the provider is a person. |
Authorized Official Middle Name |
M. |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
Authorized Official Title or Position |
OWNER |
|
Authorized Official Telephone Number |
7049415677 |
The 10-position telephone number of the authorized official. |
Healthcare Provider Taxonomy Code 1 |
225100000X |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
Healthcare Provider Primary Taxonomy Switch 1 |
Y |
|
Is Organization Subpart |
N |
|
Authorized Official Credential Text |
MPT |
|
Healthcare Provider Taxonomy Group 1 |
193400000X SINGLE SPECIALTY GROUP |
|
NPI Certification Date |
4/3/2024 |
|