MEDICARE: KEL Z GASKIN PROCK MSR, OTR L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225XP0200X	Pediatric Occupational Therapist	2713	SC
2	225X00000X	Occupational Therapist	2713	SC

General Provider Information

NPI Number	:	1003034331
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEL Z GASKIN PROCK MSR, OTR L

Provider Business Mailing Address
First Line	:	3603 KINGSLEY DR
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29588-7713
Country	:	US
Telephone Number	:	843-424-5450
Fax Number	:

Provider Business Practice Location Address
First Line	:	3603 KINGSLEY DR
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29588-7713
Country	:	US
Telephone Number	:	843-424-5450
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/23/2007
Last Update Date	:	07/31/2023

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