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General NPI Number Information
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NPI Number | 1346859881
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Entity Type | Organization
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Legal Business Name | WAVE PHYSICAL THERAPY LLC
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Dates
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Enumeration Date | 07/30/2020
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Last Update Date | 07/30/2020
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Provider Practice Location Address
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Address Line | 211 OAKWOOD DR
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City | SUMMERVILLE
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State | SC
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Zip | 29483-9701
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Country | US
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Telephone | 843-437-8184
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Fax |
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Provider Business Mailing Address
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Address Line | 211 OAKWOOD DR
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City | SUMMERVILLE
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State | SC
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Zip | 29483-9701
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Country | US
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Telephone | 843-437-8184
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JONATHAN DAVID BLACKWELL
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Credential | MSPT
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Telephone | 843-437-8184
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number |
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License Number State |
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