Basic Information
| Provider Information | |||||||||
| NPI: | 1184973489 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | YOUR LIFE WELLNESS AND PHYSICAL THERAPY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 7580 CHARLOTTE HWY | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | INDIAN LAND | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297077801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8035485662 | ||||||||
| FaxNumber: | 8035485635 | ||||||||
| Practice Location | |||||||||
| Address1: | 7580 CHARLOTTE HWY | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | INDIAN LAND | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297077801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8035485662 | ||||||||
| FaxNumber: | 8035485635 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2012 | ||||||||
| LastUpdateDate: | 08/31/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GASTON | ||||||||
| AuthorizedOfficialFirstName: | LEE | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PHYSICAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 8035485662 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | P. TL | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | 2342 | SC | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.