Healthcare Provider Details

I. General information

NPI: 1851129977
Provider Name (Legal Business Name): TIDAL CREEK PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2024
Last Update Date: 01/06/2025
Certification Date: 01/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 SEA ISLAND PKWY STE 103
BEAUFORT SC
29907-1499
US

IV. Provider business mailing address

11 ROBERT SMALLS PKWY
BEAUFORT SC
29906-4202
US

V. Phone/Fax

Practice location:
  • Phone: 843-379-3991
  • Fax:
Mailing address:
  • Phone: 843-379-3991
  • Fax: 843-582-0283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JEREMY CANNON
Title or Position: PTA
Credential: PTA
Phone: 843-379-3991