MEDICARE: YOUNG 4 LIFE REHAB

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	1811	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1225206196	OTHER	SC	INDIVIDUAL NPI

General Provider Information

NPI Number	:	1639347487
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	YOUNG 4 LIFE REHAB

Provider Business Mailing Address
First Line	:	528 ARCOLA DR
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29223-5407
Country	:	US
Telephone Number	:	803-736-1759
Fax Number	:	803-736-0374

Provider Business Practice Location Address
First Line	:	528 ARCOLA DR
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29223-5407
Country	:	US
Telephone Number	:	803-736-1759
Fax Number	:	803-736-0374

Authorized Official
Title or Position	:	OWNER
Name	:	KATRINA RENISE YOUNG
Credential	:	LPTA
Telephone Number	:	803-736-1759

Provider Enumeration Date	:	02/14/2008
Last Update Date	:	02/14/2008

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Directions to “YOUNG 4 LIFE REHAB ” Practice Location

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