Organization
JACKSONVILLE PEAK PERFORMANCE SPORTS & PHYSICAL THERAPY, L.L.C.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JOSEPH LAURENT (AUTHORIZED OFFICIAL)
(616) 356-5011
Entity
Organization
Contact information
Practice address
122 BRANCHWOOD SHOPPING CTR, JACKSONVILLE, NC 28546-5800
(910) 938-7555
(910) 938-7544
Mailing address
607 DEWEY AVE NW, SUITE 300, GRAND RAPIDS, MI 49504-7335
(616) 356-5000
(616) 356-5001
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
017PR
BLUE CROSS BLUE SHIELD
NC
05
—
7211944
—
NC
Enumeration date
03/23/2006
Last updated
04/30/2018
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