Healthcare Provider Details

I. General information

NPI: 1386236149
Provider Name (Legal Business Name): MACKENZIE TAYLOR BILYARD PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2021
Last Update Date: 02/03/2021
Certification Date: 02/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1076 RIBAUT RD STE 102
BEAUFORT SC
29902-5490
US

IV. Provider business mailing address

2674 GRAYS HWY
RIDGELAND SC
29936-4402
US

V. Phone/Fax

Practice location:
  • Phone: 843-521-1970
  • Fax:
Mailing address:
  • Phone: 843-422-4844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number4582
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: