MEDICARE: OTIS WINSTON CLARK 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	PT009950	GA
2	225100000X	Physical Therapist	7643	SC

General Provider Information

NPI Number	:	1477864312
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OTIS WINSTON CLARK DPT

Provider Business Mailing Address
First Line	:	3250 HARDEN STREET EXT
Second Line	:	SUITE 100
City	:	COLUMBIA
State	:	SC
Zip	:	29203-6842
Country	:	US
Telephone Number	:	803-509-6389
Fax Number	:	803-509-6390

Provider Business Practice Location Address
First Line	:	3250 HARDEN STREET EXT
Second Line	:	SUITE 100
City	:	COLUMBIA
State	:	SC
Zip	:	29203-6842
Country	:	US
Telephone Number	:	803-509-6389
Fax Number	:	803-509-6390

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

Provider Enumeration Date	:	06/25/2010
Last Update Date	:	01/16/2015

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