Healthcare Provider Details

I. General information

NPI: 1720350853
Provider Name (Legal Business Name): KELLEY WOOD HERNDON PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELLEY MARIE WOOD

II. Dates (important events)

Enumeration Date: 02/06/2012
Last Update Date: 02/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7601 PARKLANE RD
COLUMBIA SC
29223-6122
US

IV. Provider business mailing address

7601 PARKLANE RD
COLUMBIA SC
29223-6122
US

V. Phone/Fax

Practice location:
  • Phone: 803-741-9090
  • Fax: 803-741-7216
Mailing address:
  • Phone: 803-741-9090
  • Fax: 803-741-7216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2723S
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: