Healthcare Provider Details

I. General information

NPI: 1629367693
Provider Name (Legal Business Name): GYROTONIC VISTA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2011
Last Update Date: 03/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

911 LADY ST SUITE H
COLUMBIA SC
29201-3105
US

IV. Provider business mailing address

911 LADY ST SUITE H
COLUMBIA SC
29201-3105
US

V. Phone/Fax

Practice location:
  • Phone: 803-758-5962
  • Fax:
Mailing address:
  • Phone: 803-758-5962
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0724727
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code225600000X
TaxonomyDance Therapist
License Number0724727
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number0724727
License Number StateSC
# 4
Primary TaxonomyY
Taxonomy Code225500000X
TaxonomyRespiratory/Developmental/Rehabilitative Specialist/Technologist
License Number0724727
License Number StateSC

VIII. Authorized Official

Name: MR. CHARLES C PULLIAM
Title or Position: MANAGER
Credential:
Phone: 803-758-5962