Healthcare Provider Details

I. General information

NPI: 1366770968
Provider Name (Legal Business Name): DWAYNE M DUCKETT P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2009
Last Update Date: 11/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 BROUGHTON ST
ORANGEBURG SC
29115-4867
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 Code225100000X
TaxonomyPhysical Therapist
License Number1458
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: