1184828980 NPI number — WALTERBORO PHYSICAL THERAPY WORKS LLC

Table of content: (NPI 1184828980)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184828980 NPI number — WALTERBORO PHYSICAL THERAPY WORKS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WALTERBORO PHYSICAL THERAPY WORKS LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
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NPI Number Information

NPI Number:
1184828980
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
743 BELLS HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WALTERBORO
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29488-2707
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
743 BELLS HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALTERBORO
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29488-2707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-549-6487
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/14/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PANGALANGAN
Authorized Official First Name:
WALTER
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PHYSICAL THERAPIST OWNER
Authorized Official Telephone Number:
843-549-6487

Provider Taxonomy Codes

  • Taxonomy code: 2251X0800X , with the licence number:  SC4348 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: TH1626 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1720020183 . This is a "NPI" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".