Healthcare Provider Details

I. General information

NPI: 1912177809
Provider Name (Legal Business Name): SHELLY ANN BUMGARNER PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2008
Last Update Date: 03/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 W MARTINTOWN RD
NORTH AUGUSTA SC
29841-3194
US

IV. Provider business mailing address

401 W MARTINTOWN RD
NORTH AUGUSTA SC
29841-3194
US

V. Phone/Fax

Practice location:
  • Phone: 803-441-0025
  • Fax:
Mailing address:
  • Phone: 803-441-0025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number558
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA002163
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: