Healthcare Provider Details

I. General information

NPI: 1720176241
Provider Name (Legal Business Name): DUCKETT PHYSICAL THERAPY & SPORTS REHAB CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 BROUGHTON ST.
ORANGEBURG SC
29115
US

IV. Provider business mailing address

1620 BROUGHTON ST.
ORANGEBURG SC
29115
US

V. Phone/Fax

Practice location:
  • Phone: 803-534-4050
  • Fax: 803-534-0408
Mailing address:
  • Phone: 803-534-4050
  • Fax: 803-534-0408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number1458
License Number StateSC

VIII. Authorized Official

Name: MR. DWAYNE M. DUCKETT
Title or Position: OWNER/DIRECTOR
Credential: PT, MTC
Phone: 803-534-4050