Healthcare Provider Details

I. General information

NPI: 1336704717
Provider Name (Legal Business Name): ADVANCED MSK MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4016 RIVER OAKS DRIVE
MYRTLE BEACH SC
29579-8487
US

IV. Provider business mailing address

4016 RIVER OAKS DRIVE P.O. BOX 172
MYRTLE BEACH SC
29579
US

V. Phone/Fax

Practice location:
  • Phone: 843-742-7922
  • Fax: 843-796-1492
Mailing address:
  • Phone: 843-742-7922
  • Fax: 843-796-1492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: JACK DWYER SCOTT
Title or Position: OWNER
Credential: DC
Phone: 843-742-7922