MEDICARE: ADENA M. KELLY GROVE PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant

General Provider Information

NPI Number	:	1023118213
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ADENA M. KELLY GROVE PTA

Provider Business Mailing Address
First Line	:	9225 UNIVERSITY BLVD
Second Line	:	STE. D
City	:	NORTH CHARLESTON
State	:	SC
Zip	:	29406-9149
Country	:	US
Telephone Number	:	843-569-4546
Fax Number	:	843-569-4535

Provider Business Practice Location Address
First Line	:	9225 UNIVERSITY BLVD
Second Line	:	STE. D
City	:	NORTH CHARLESTON
State	:	SC
Zip	:	29406-9149
Country	:	US
Telephone Number	:	843-569-4546
Fax Number	:	843-569-4535

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/25/2006
Last Update Date	:	07/08/2007

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