Healthcare Provider Details

I. General information

NPI: 1245772755
Provider Name (Legal Business Name): ACKER PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2016
Last Update Date: 07/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

144 LEISURE LN STE 100
COLUMBIA SC
29210-4156
US

IV. Provider business mailing address

144 LEISURE LN STE 100
COLUMBIA SC
29210-4156
US

V. Phone/Fax

Practice location:
  • Phone: 803-331-3682
  • Fax: 803-791-3862
Mailing address:
  • Phone: 803-888-6125
  • Fax: 803-888-6085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number5266
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number1580
License Number StateSC

VIII. Authorized Official

Name: SHANNON DANESE LOTT
Title or Position: BILLING/CREDENTIALING MANAGER
Credential:
Phone: 803-667-1819