Healthcare Provider Details

I. General information

NPI: 1720787773
Provider Name (Legal Business Name): MICHAEL JOHN DESMADRYL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2023
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 VILLAGE CENTER BLVD STE 100
MYRTLE BEACH SC
29579-6706
US

IV. Provider business mailing address

210 VILLAGE CENTER BLVD STE 100
MYRTLE BEACH SC
29579-6706
US

V. Phone/Fax

Practice location:
  • Phone: 843-353-3460
  • Fax: 843-353-3461
Mailing address:
  • Phone: 843-353-3460
  • Fax: 843-353-3460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number11768
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: