1114322625 NPI number — ELIZABETH CORBETT, LLC

Table of content: PATRICK RICHAD KILDUFF PT, DPT, LSVT (NPI 1265948681)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114322625 NPI number — ELIZABETH CORBETT, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELIZABETH CORBETT, 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:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114322625
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/27/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
105 LAZY ACRES DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29209-4255
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-361-7940
Provider Business Mailing Address Fax Number:
803-695-4934

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1612 MARION ST
Provider Second Line Business Practice Location Address:
SUITE 311
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29201-2939
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-361-7940
Provider Business Practice Location Address Fax Number:
803-695-4935
Provider Enumeration Date:
10/27/2014

Additional Information

Authorized Official

Authorized Official Last Name:
CORBETT
Authorized Official First Name:
ELIZABETH
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
803-361-7940

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  4991 , 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: SW1153 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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