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General NPI Number Information
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NPI Number | 1477351757
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Entity Type | Individual
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Provider Name | SAMANTHA LEIGH TADLOCK PTA
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Gender | Female
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Dates
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Enumeration Date | 03/04/2025
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Last Update Date | 03/04/2025
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Provider Practice Location Address
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Address Line | 100 ALLAWOOD CT STE 110
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City | SIMPSONVILLE
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State | SC
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Zip | 29681-6207
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Country | US
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Telephone | 864-525-2654
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Fax | 864-757-8811
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Provider Business Mailing Address
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Address Line | 1601 RONALD ST
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City | CHARLOTTE
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State | NC
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Zip | 28216-2637
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Country | US
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Telephone | 704-995-0407
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 6777
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License Number State | SC
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