MEDICARE: YOUR LIFE WELLNESS AND PHYSICAL THERAPY

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	261QP2000X	Physical Therapy Clinic/Center	2342	SC

General Provider Information

NPI Number	:	1184973489
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	YOUR LIFE WELLNESS AND PHYSICAL THERAPY

Provider Business Mailing Address
First Line	:	7580 CHARLOTTE HWY
Second Line	:	SUITE 500
City	:	INDIAN LAND
State	:	SC
Zip	:	29707-7801
Country	:	US
Telephone Number	:	803-548-5662
Fax Number	:	803-548-5635

Provider Business Practice Location Address
First Line	:	7580 CHARLOTTE HWY
Second Line	:	SUITE 500
City	:	INDIAN LAND
State	:	SC
Zip	:	29707-7801
Country	:	US
Telephone Number	:	803-548-5662
Fax Number	:	803-548-5635

Authorized Official
Title or Position	:	OWNER/PHYSICAL THERAPIST
Name	:	MRS. LEE ANN GASTON
Credential	:	P. TL
Telephone Number	:	803-548-5662

Provider Enumeration Date	:	08/31/2012
Last Update Date	:	08/31/2012

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