1952491490 NPI number — CAROLINA PHYSICAL THERAPY AND SPORTS MEDICINE, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952491490 NPI number — CAROLINA PHYSICAL THERAPY AND SPORTS MEDICINE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAROLINA PHYSICAL THERAPY AND SPORTS MEDICINE, 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:
1952491490
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/04/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
115 ATRIUM WAY
Provider Second Line Business Mailing Address:
SUITE 232
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29223-6383
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-788-8484
Provider Business Mailing Address Fax Number:
803-788-8499

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 ATRIUM WAY
Provider Second Line Business Practice Location Address:
SUITE 232
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29223-6383
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-788-8484
Provider Business Practice Location Address Fax Number:
803-788-8499
Provider Enumeration Date:
10/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BALLEW
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
OWNER/DIRECTOR
Authorized Official Telephone Number:
803-788-8484

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  1888 , 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: GP4712 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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