Basic Information
| Provider Information | |||||||||
| NPI: | 1609940394 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LONG BAY REHAB, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 220 | ||||||||
| Address2: | |||||||||
| City: | CHAPIN | ||||||||
| State: | SC | ||||||||
| PostalCode: | 290360220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432935610 | ||||||||
| FaxNumber: | 8432935690 | ||||||||
| Practice Location | |||||||||
| Address1: | 4871 SOCASTEE BLVD UNIT E | ||||||||
| Address2: | |||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295887252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432935610 | ||||||||
| FaxNumber: | 8432935690 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2006 | ||||||||
| LastUpdateDate: | 11/16/2007 | ||||||||
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| AuthorizedOfficialLastName: | SHELTON | ||||||||
| AuthorizedOfficialFirstName: | CATHERINE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 8432935610 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | P.T. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 3584 | SC | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | GP3715 | 05 | SC | MEDICAID |