MEDICARE: IMAGINE PHYSICAL THERAPY IN WEST ASHLEY, LLC

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1588977862
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMAGINE PHYSICAL THERAPY IN WEST ASHLEY, LLC

Provider Business Mailing Address
First Line	:	5111 NORTH RHETT AVENUE
Second Line	:	IMAGINE PHYSICAL THERAPY
City	:	NORTH CHARLESTON
State	:	SC
Zip	:	29405-4219
Country	:	US
Telephone Number	:	843-804-9077
Fax Number	:	843-804-9020

Provider Business Practice Location Address
First Line	:	2267 ASHLEY RIVER ROAD
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29414-4736
Country	:	US
Telephone Number	:	843-576-4121
Fax Number	:	843-793-3575

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	BETH WILLIAMSON
Credential	:
Telephone Number	:	843-804-9479

Provider Enumeration Date	:	07/15/2010
Last Update Date	:	05/12/2023

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