1083943815 NPI number — PRS II, LLC

Table of content: (NPI 1083943815)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083943815 NPI number — PRS II, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRS II, 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:
PROFESSIONAL REHABILITATION SERVICES
Provider Other Organization Name Type Code:
3
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:
1083943815
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/28/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2397
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PAWLEYS ISLAND
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29585-2397
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-235-0200
Provider Business Mailing Address Fax Number:
843-235-0242

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3076 DICK POND ROAD UNIT 4
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MYRTLE BEACH
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29575
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-831-0163
Provider Business Practice Location Address Fax Number:
843-831-0173
Provider Enumeration Date:
12/07/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KINMARTIN
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
PATRICK
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
843-831-0163

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  3690 , 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: GP5324 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: DQ9787 . This is a "RAILROAD MEDICARE PTAN" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".