Healthcare Provider Details

I. General information

NPI: 1265700058
Provider Name (Legal Business Name): ELAINE MARIE FLYNN COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2011
Last Update Date: 12/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 BRIGHTWATER DR
MYRTLE BEACH SC
29579-8275
US

IV. Provider business mailing address

2110 SILVERCREST DR UNIT D
MYRTLE BEACH SC
29579-4388
US

V. Phone/Fax

Practice location:
  • Phone: 843-903-8300
  • Fax:
Mailing address:
  • Phone: 843-903-3131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number3043
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: