Healthcare Provider Details

I. General information

NPI: 1215164892
Provider Name (Legal Business Name): KRISTOPHER MICHAEL PHILLIPS DPT, OCS, OMT-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2009
Last Update Date: 06/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 SALUDA POINTE DRIVE SUITE G
LEXINGTON SC
29072
US

IV. Provider business mailing address

136 PARK PLACE CIRCLE
LEXINGTON SC
29072
US

V. Phone/Fax

Practice location:
  • Phone: 803-227-8008
  • Fax: 803-227-8038
Mailing address:
  • Phone: 864-903-5726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5979
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: