MEDICARE: TIDELANDS REHABILITATION GROUP 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	261QR0401X	Comprehensive Outpatient Rehabilitation Facility (CORF)	0000	SC

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	:	1972961910
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIDELANDS REHABILITATION GROUP LLC

Provider Business Mailing Address
First Line	:	4000 FABER PLACE DR
Second Line	:	SUITE 300
City	:	NORTH CHARLESTON
State	:	SC
Zip	:	29405-8585
Country	:	US
Telephone Number	:	843-870-8822
Fax Number	:	843-388-0349

Provider Business Practice Location Address
First Line	:	4000 FABER PLACE DR
Second Line	:	SUITE 300
City	:	NORTH CHARLESTON
State	:	SC
Zip	:	29405-8585
Country	:	US
Telephone Number	:	843-870-8822
Fax Number	:	843-388-0349

Authorized Official
Title or Position	:	COO
Name	:	MRS. LINA MARIA NORENA
Credential	:
Telephone Number	:	843-870-8822

Provider Enumeration Date	:	02/05/2016
Last Update Date	:	02/05/2016

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