Basic Information
Provider Information | |||||||||
NPI: | 1548727019 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PROGRESSIVE REHAB AND WELLNESS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 458 ANVIL DRAW PL | ||||||||
Address2: |   | ||||||||
City: | ROCK HILL | ||||||||
State: | SC | ||||||||
PostalCode: | 297309236 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8035773701 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 403 W MEETING ST | ||||||||
Address2: |   | ||||||||
City: | LANCASTER | ||||||||
State: | SC | ||||||||
PostalCode: | 297202321 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8034168000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/21/2019 | ||||||||
LastUpdateDate: | 02/21/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GILL | ||||||||
AuthorizedOfficialFirstName: | MARK | ||||||||
AuthorizedOfficialMiddleName: | ANTHONY | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER, PARTNER | ||||||||
AuthorizedOfficialTelephone: | 8284494804 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | OTR/L | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   | 235Z00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   | 225X00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   |
No ID Information.