MEDICARE: MYRTLE BEACH PHYSICAL MEDICINE & REHAB, 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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1760806160
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MYRTLE BEACH PHYSICAL MEDICINE & REHAB, LLC

Provider Business Mailing Address
First Line	:	4736 17 BYPASS SOUTH
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29588
Country	:	US
Telephone Number	:	843-444-9355
Fax Number	:	843-294-0019

Provider Business Practice Location Address
First Line	:	4736 17 BYPASS SOUTH
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29588
Country	:	US
Telephone Number	:	843-444-9355
Fax Number	:	843-294-0019

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MARK LUCKIE
Credential	:
Telephone Number	:	843-444-9355

Provider Enumeration Date	:	02/06/2014
Last Update Date	:	02/06/2014

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