Basic Information
| Provider Information | |||||||||
| NPI: | 1144331901 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MYRICK | ||||||||
| FirstName: | TERESA | ||||||||
| MiddleName: | RIGGS | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 WILLIAM PENN PLZ | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277042150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192205255 | ||||||||
| FaxNumber: | 9193131276 | ||||||||
| Practice Location | |||||||||
| Address1: | 171 NC HIGHWAY 125 | ||||||||
| Address2: | |||||||||
| City: | ROANOKE RAPIDS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278706460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2525375639 | ||||||||
| FaxNumber: | 2525377198 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 09/02/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 3107 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 61691 | 01 | NC | BCBSNC | OTHER | 7210475 | 05 | NC | MEDICAID |