Healthcare Provider Details

I. General information

NPI: 1306074885
Provider Name (Legal Business Name): RIVERTOWN LYMPHEDEMA CLINIC AND REHAB, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2009
Last Update Date: 06/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 PRATHER PARK DR SUITE A
MYRTLE BEACH SC
29588-7910
US

IV. Provider business mailing address

100 PRATHER PARK DR SUITE A
MYRTLE BEACH SC
29588-7910
US

V. Phone/Fax

Practice location:
  • Phone: 843-742-5701
  • Fax: 843-742-5704
Mailing address:
  • Phone: 843-742-5701
  • Fax: 843-742-5704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
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: THOMAS ANDREW KINCHELOE
Title or Position: OWNER/ADMINISTRATOR
Credential: OTR/L, CLT
Phone: 843-742-5701