=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770435299
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ETHAN DUTKA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/10/2026
-----------------------------------------------------
Last Update Date | 02/10/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 420 THE PKWY STE D
-----------------------------------------------------
City | GREER
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29650-5206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-879-7757
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 215 EDMONDSTON DR BLDG 116
-----------------------------------------------------
City | PIEDMONT
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29673-6423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 13232
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------