Healthcare Provider Details

I. General information

NPI: 1114943099
Provider Name (Legal Business Name): SOUTHERN STATES PHYSICAL MEDICINE AND REHABILIATION CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8763 CHARLOTTE HWY
FORT MILL SC
29715-7589
US

IV. Provider business mailing address

1002 N WOODLAND DR
LANCASTER SC
29720-1966
US

V. Phone/Fax

Practice location:
  • Phone: 803-548-8452
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2158
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3884
License Number StateSC

VIII. Authorized Official

Name: GLENN GEADA
Title or Position: OWNER
Credential:
Phone: 803-283-8442