Healthcare Provider Details

I. General information

NPI: 1265571558
Provider Name (Legal Business Name): FAITHWORKS PEDIATRIC INNERVATIONS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 MOORE ST
LAKE CITY SC
29560-2551
US

IV. Provider business mailing address

300 THURSTON ST
LAKE CITY SC
29560-2527
US

V. Phone/Fax

Practice location:
  • Phone: 843-394-9799
  • Fax: 843-394-9899
Mailing address:
  • Phone: 843-394-9799
  • Fax: 843-394-9899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number4703
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number177
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number1113
License Number StateSC

VIII. Authorized Official

Name: BETTY MCKENZIE
Title or Position: OWNER
Credential: SPEECH PATHOLOGIST
Phone: 843-394-9799