Healthcare Provider Details

I. General information

NPI: 1811473390
Provider Name (Legal Business Name): LEWIS EDWARD GORE III PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2018
Last Update Date: 07/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1787 ALLENDALE FAIRFAX HWY
FAIRFAX SC
29827-9133
US

IV. Provider business mailing address

406 S MAIN ST
SYLVANIA GA
30467-2226
US

V. Phone/Fax

Practice location:
  • Phone: 803-632-3421
  • Fax:
Mailing address:
  • Phone: 843-446-2461
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number7872
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: