MEDICARE: DEIRDRE C DAVIS LPTA

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	225200000X	Physical Therapy Assistant	387	SC

General Provider Information

NPI Number	:	1417073495
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEIRDRE C DAVIS LPTA

Provider Business Mailing Address
First Line	:	4746 CASCADE AVE
Second Line	:
City	:	ROCK HILL
State	:	SC
Zip	:	29732-8190
Country	:	US
Telephone Number	:	803-325-4280
Fax Number	:

Provider Business Practice Location Address
First Line	:	1075 BAYSHORE DR
Second Line	:
City	:	ROCK HILL
State	:	SC
Zip	:	29732-1569
Country	:	US
Telephone Number	:	803-327-8655
Fax Number	:	803-327-8664

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

Provider Enumeration Date	:	03/22/2007
Last Update Date	:	07/08/2007

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