MEDICARE: KATHLEEN MULL POOLE P.T.

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	2251P0200X	Pediatric Physical Therapist	5159	SC

General Provider Information

NPI Number	:	1053550954
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN MULL POOLE P.T.

Provider Business Mailing Address
First Line	:	3402 WILMOT AVE
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29205-2727
Country	:	US
Telephone Number	:	803-553-5330
Fax Number	:

Provider Business Practice Location Address
First Line	:	3402 WILMOT AVE
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29205-2727
Country	:	US
Telephone Number	:	803-553-5330
Fax Number	:

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

Provider Enumeration Date	:	02/17/2009
Last Update Date	:	02/17/2009

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