Healthcare Provider Details

I. General information

NPI: 1144458381
Provider Name (Legal Business Name): PAUL G MARTINO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2009
Last Update Date: 06/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2166 GOLD HILL RD STE B
TEGA CAY SC
29708-8384
US

IV. Provider business mailing address

7349 WINDYRUSH RD
CHARLOTTE NC
28226-3111
US

V. Phone/Fax

Practice location:
  • Phone: 803-802-5508
  • Fax:
Mailing address:
  • Phone: 704-562-4770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number1631
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: