Healthcare Provider Details

I. General information

NPI: 1427644566
Provider Name (Legal Business Name): NICOLA FERNANDO GUALTIERI PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2020
Last Update Date: 10/20/2022
Certification Date: 10/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

439 CHANNEL RD STE 102
LAKE WYLIE SC
29710-6101
US

IV. Provider business mailing address

1377 MOTOR PKWY STE 307
ISLANDIA NY
11749-5258
US

V. Phone/Fax

Practice location:
  • Phone: 803-746-7800
  • Fax: 803-746-7807
Mailing address:
  • Phone: 914-294-4050
  • Fax: 631-760-8306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberP20933
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number10524
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: