Organization
MBODY PHYSICAL THERAPY, LLC
Active
Other names
MBody Physical Therapy
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. LISA MARIE VANDER BLOOMER PT (OWNER / PHYSICAL THERAPIST)
(980) 288-4646
Entity
Organization
Contact information
Practice address
5200 PARK ROAD, SUITE 235, CHARLOTTE, NC 28209-3651
(980) 288-4646
Mailing address
5200 PARK ROAD, SUITE 235, CHARLOTTE, NC 28209-3651
(980) 288-4646
Taxonomy
Speciality
Code
Description
License number
State
2251X0800X
Orthopedic Physical Therapist
Primary
14338
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
Q44318A
MEDICARE PTAN
NC
Enumeration date
06/24/2015
Last updated
06/25/2015
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