| Organization Name: | OPTIMUM REHAB & SPORTS TRAINING, LLC |
| NPI Number: | 1003165663 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | MARK DUFAULT (OWNER/PHYSICAL THERAPIST) |
| Mailing Address: | 6405 Westgate Rd Suite 105 Raleigh |
| State: | NC US |
| Postal Code: | 276174757 |
| Phone Number: | 9195086835 |
| Fax Number: | |
| NPI Enumeration Date: | 08/29/2012 |
| NPI Last Update Date: | 08/29/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 2251X0800X |
| License Number: | P6231 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NC |
| Taxonomy Type: | Respiratory, Developmental, Rehabilitative and Restorative Service Providers |
| Taxonomy Classification: | Physical Therapist |
| Taxonomy Specialization: | Orthopedic |
| Taxonomy Definition: | |