1316097702 NPI number — OMNI PHYSICAL THERAPY INC

Table of content: (NPI 1316097702)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316097702 NPI number — OMNI PHYSICAL THERAPY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OMNI PHYSICAL THERAPY INC
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:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316097702
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:
1647 RUBY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HARTSVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29550-2407
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-409-1620
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
126 N MACARTHUR AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DILLON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29536-3434
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-774-7462
Provider Business Practice Location Address Fax Number:
843-841-2482
Provider Enumeration Date:
01/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SHUMATE
Authorized Official First Name:
MELISSA
Authorized Official Middle Name:
KEZIAH
Authorized Official Title or Position:
PHYSICAL THERAPIST
Authorized Official Telephone Number:
843-409-1620

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  4705 , 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: TH1381 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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