Healthcare Provider Details

I. General information

NPI: 1225050271
Provider Name (Legal Business Name): SOUTHERN ORTHOPAEDIC PHYSICAL THERAPY,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 01/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1718 SAINT JULIAN PL
COLUMBIA SC
29204-2410
US

IV. Provider business mailing address

1718 SAINT JULIAN PL
COLUMBIA SC
29204-2410
US

V. Phone/Fax

Practice location:
  • Phone: 803-376-8880
  • Fax: 803-376-8881
Mailing address:
  • Phone: 803-376-8880
  • Fax: 803-376-8881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number3168
License Number StateSC

VIII. Authorized Official

Name: CYNTHIA J EKMAN
Title or Position: PRESIDENT
Credential: PYSICAL THERAPIST
Phone: 803-376-8880