Basic Information
| Provider Information | |||||||||
| NPI: | 1497724660 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KJC CORP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ADVANCE PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 77 S ELLIOTT RD | ||||||||
| Address2: | |||||||||
| City: | CHAPEL HILL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275145827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199327266 | ||||||||
| FaxNumber: | 9199327250 | ||||||||
| Practice Location | |||||||||
| Address1: | 77 S ELLIOTT RD | ||||||||
| Address2: | |||||||||
| City: | CHAPEL HILL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275145827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199327266 | ||||||||
| FaxNumber: | 9199327250 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2006 | ||||||||
| LastUpdateDate: | 03/18/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCCOLLUM | ||||||||
| AuthorizedOfficialFirstName: | DEANA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9199327266 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | DU4453 | 01 | RAILROAD MEDICARE | OTHER | 013CA | 01 | NC | BLUE CROSS OF NC | OTHER |