Healthcare Provider Details

I. General information

NPI: 1336746338
Provider Name (Legal Business Name): MONTRELLE LATWAN LEWIS PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2020
Last Update Date: 10/03/2020
Certification Date: 10/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2199 N FRASER ST
GEORGETOWN SC
29440-6409
US

IV. Provider business mailing address

7704 BROWNS FERRY RD
GEORGETOWN SC
29440-5644
US

V. Phone/Fax

Practice location:
  • Phone: 843-527-6835
  • Fax:
Mailing address:
  • Phone: 843-325-5660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number3566
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: