Healthcare Provider Details

I. General information

NPI: 1275107740
Provider Name (Legal Business Name): SANTTANU MCDANIEL SR. PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2021
Last Update Date: 05/18/2021
Certification Date: 05/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 GATEWAY CORNERS PARK STE 102
COLUMBIA SC
29203-8906
US

IV. Provider business mailing address

109 LOGGERHEAD DR
COLUMBIA SC
29229-7909
US

V. Phone/Fax

Practice location:
  • Phone: 803-699-9775
  • Fax:
Mailing address:
  • Phone: 803-529-9166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number4659
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: