MEDICARE: MRS. TAYLOR A BASTIAN DPT

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	225100000X	Physical Therapist	9161	SC

General Provider Information

NPI Number	:	1144713892
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TAYLOR A BASTIAN DPT

Provider Business Mailing Address
First Line	:	5111 N RHETT AVE
Second Line	:
City	:	NORTH CHARLESTON
State	:	SC
Zip	:	29405-4219
Country	:	US
Telephone Number	:	843-804-9033
Fax Number	:	843-804-9020

Provider Business Practice Location Address
First Line	:	142 SPORTSMAN ISLAND DR STE F
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29492-8524
Country	:	US
Telephone Number	:	843-377-8820
Fax Number	:	843-377-8823

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

Provider Enumeration Date	:	06/07/2018
Last Update Date	:	02/22/2021

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