MEDICARE: MRS. BONNIE ALLEN BOTTOMS P.T.A.

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	577	SC
2	225200000X	Physical Therapy Assistant	1773	NC

General Provider Information

NPI Number	:	1598718280
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. BONNIE ALLEN BOTTOMS P.T.A.

Provider Business Mailing Address
First Line	:	543 HIGHWAY 17 N
Second Line	:
City	:	NORTH MYRTLE BEACH
State	:	SC
Zip	:	29582-2903
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	543 HIGHWAY 17 N
Second Line	:
City	:	NORTH MYRTLE BEACH
State	:	SC
Zip	:	29582-2903
Country	:	US
Telephone Number	:	843-249-7232
Fax Number	:

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

Provider Enumeration Date	:	05/17/2006
Last Update Date	:	07/08/2007

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