MEDICARE: SUPERKIDZ PEDIATRIC THERAPY, 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	225100000X	Physical Therapist
2	225X00000X	Occupational Therapist

General Provider Information

NPI Number	:	1699155317
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUPERKIDZ PEDIATRIC THERAPY, LLC

Provider Business Mailing Address
First Line	:	PO BOX 2791
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29202-2791
Country	:	US
Telephone Number	:	803-509-3459
Fax Number	:

Provider Business Practice Location Address
First Line	:	1700 QUAIL LAKE DR
Second Line	:
City	:	WEST COLUMBIA
State	:	SC
Zip	:	29169-3746
Country	:	US
Telephone Number	:	803-509-3459
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MRS. KIMBERLY B CALDWELL
Credential	:
Telephone Number	:	803-509-3459

Provider Enumeration Date	:	06/08/2015
Last Update Date	:	06/08/2015

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