Healthcare Provider Details

I. General information

NPI: 1063971695
Provider Name (Legal Business Name): LAUREN MICHELLE AUDLIN DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2019
Last Update Date: 01/12/2024
Certification Date: 01/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2720 SUNSET BLVD
WEST COLUMBIA SC
29169-4810
US

IV. Provider business mailing address

2204 TRADE ST
WEST COLUMBIA SC
29169-7683
US

V. Phone/Fax

Practice location:
  • Phone: 803-791-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number11961
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number041921
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: