MEDICARE: SOURCE LINGUISTICS PHYSICAL THERAPY -REHABILITATION CENTER

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	1581	SC

General Provider Information

NPI Number	:	1184102535
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOURCE LINGUISTICS PHYSICAL THERAPY -REHABILITATION CENTER

Provider Business Mailing Address
First Line	:	1125 ELMGROVE AVE
Second Line	:
City	:	FLORENCE
State	:	SC
Zip	:	29506-6312
Country	:	US
Telephone Number	:	843-206-9325
Fax Number	:

Provider Business Practice Location Address
First Line	:	111 N MATTHEWS RD
Second Line	:
City	:	LAKE CITY
State	:	SC
Zip	:	29560-2309
Country	:	US
Telephone Number	:	843-394-5618
Fax Number	:	843-394-5618

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	HARRY L MONTGOMERY
Credential	:
Telephone Number	:	843-206-9325

Provider Enumeration Date	:	07/29/2018
Last Update Date	:	07/24/2019

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