MEDICARE: DR. CARL GABRIEL BOTERO PT, 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	11481	SC

General Provider Information

NPI Number	:	1205564473
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CARL GABRIEL BOTERO PT, DPT

Provider Business Mailing Address
First Line	:	434 CARRIAGE LN
Second Line	:
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29464-3003
Country	:	US
Telephone Number	:	843-609-5405
Fax Number	:

Provider Business Practice Location Address
First Line	:	1300 HOSPITAL DR STE 220
Second Line	:
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29464-3208
Country	:	US
Telephone Number	:	843-936-6238
Fax Number	:

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

Provider Enumeration Date	:	08/15/2022
Last Update Date	:	08/15/2022

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