Healthcare Provider Details

I. General information

NPI: 1972961910
Provider Name (Legal Business Name): TIDELANDS REHABILITATION GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2016
Last Update Date: 02/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 FABER PLACE DR SUITE 300
NORTH CHARLESTON SC
29405-8585
US

IV. Provider business mailing address

4000 FABER PLACE DR SUITE 300
NORTH CHARLESTON SC
29405-8585
US

V. Phone/Fax

Practice location:
  • Phone: 843-870-8822
  • Fax: 843-388-0349
Mailing address:
  • Phone: 843-870-8822
  • Fax: 843-388-0349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number0000
License Number StateSC

VIII. Authorized Official

Name: MRS. LINA MARIA NORENA
Title or Position: COO
Credential:
Phone: 843-870-8822