1114943099 NPI number — SOUTHERN STATES PHYSICAL MEDICINE AND REHABILIATION CENTER

Table of content: (NPI 1114943099)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114943099 NPI number — SOUTHERN STATES PHYSICAL MEDICINE AND REHABILIATION CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN STATES PHYSICAL MEDICINE AND REHABILIATION CENTER
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:
SOUTHERN STATES FAMILY HEALTH CENTER
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:
1114943099
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:
1002 N WOODLAND DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LANCASTER
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29720-1966
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:
8763 CHARLOTTE HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT MILL
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29715-7589
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-548-8452
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GEADA
Authorized Official First Name:
GLENN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
803-283-8442

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  2158 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 225100000X , with the licence number: 3884 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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





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