Healthcare Provider Details

I. General information

NPI: 1760095178
Provider Name (Legal Business Name): ELIZABETH CUNNINGHAM OWEN DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2020
Last Update Date: 08/25/2020
Certification Date: 08/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3620 COVENANT RD
COLUMBIA SC
29204-4216
US

IV. Provider business mailing address

5000 WITTERING DR
COLUMBIA SC
29206-2923
US

V. Phone/Fax

Practice location:
  • Phone: 803-787-3003
  • Fax:
Mailing address:
  • Phone: 803-528-8033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number10354
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: