1285024836 NPI number — SOUTHERN STATES PHYSICAL THERAPY LLC

Table of content: (NPI 1285024836)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285024836 NPI number — SOUTHERN STATES PHYSICAL THERAPY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN STATES PHYSICAL THERAPY 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:
1285024836
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/24/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2670 MILLS PARK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCK HILL
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29732-8599
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-324-3745
Provider Business Mailing Address Fax Number:
803-324-9845

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
106A WOODLAND DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LANCASTER
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29720-4707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-283-8442
Provider Business Practice Location Address Fax Number:
803-286-4604
Provider Enumeration Date:
02/03/2015

Additional Information

Authorized Official

Authorized Official Last Name:
FAKER
Authorized Official First Name:
RYAN
Authorized Official Middle Name:
CHRISTOPHER
Authorized Official Title or Position:
OWNER/PHYSICAL THERAPIST
Authorized Official Telephone Number:
704-578-0641

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  4533 , 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: 13501810 . This is a "CAQH" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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