Healthcare Provider Details

I. General information

NPI: 1639460330
Provider Name (Legal Business Name): CAROLINA PEDIATRIC THERAPY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2011
Last Update Date: 05/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

538 WILD HORSE CT
MYRTLE BEACH SC
29579-7577
US

IV. Provider business mailing address

538 WILD HORSE CT
MYRTLE BEACH SC
29579-7577
US

V. Phone/Fax

Practice location:
  • Phone: 843-455-2415
  • Fax: 843-903-2742
Mailing address:
  • Phone: 843-455-2415
  • Fax: 843-903-2742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3841
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2608
License Number StateSC

VIII. Authorized Official

Name: MISS TAMMY LYNN PRIGANC
Title or Position: PHYSICAL THERAPIST
Credential: MSPT
Phone: 843-455-2415