Healthcare Provider Details

I. General information

NPI: 1356995211
Provider Name (Legal Business Name): OKATIE PHYSICAL THERAPY AND SPORTS MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2019
Last Update Date: 07/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

149 RIVERWALK BLVD STE 3
RIDGELAND SC
29936-8191
US

IV. Provider business mailing address

15 MOSS CREEK VLG
HILTON HEAD SC
29926-1105
US

V. Phone/Fax

Practice location:
  • Phone: 843-645-2668
  • Fax:
Mailing address:
  • Phone: 843-681-5077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: J. ROBERT GAVIN
Title or Position: OWNER
Credential: MD
Phone: 843-645-2668