Healthcare Provider Details

I. General information

NPI: 1386434074
Provider Name (Legal Business Name): FORT MILL SPINE AND SPORTS REHAB, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2025
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1096 ASSEMBLY DR STE 310
FORT MILL SC
29708-6450
US

IV. Provider business mailing address

1096 ASSEMBLY DR STE 310
FORT MILL SC
29708-6450
US

V. Phone/Fax

Practice location:
  • Phone: 803-547-9800
  • Fax:
Mailing address:
  • Phone: 803-547-9800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: FIKRI SOUSSI
Title or Position: OWNER
Credential:
Phone: 803-547-9800