Basic Information
| Provider Information | |||||||||
| NPI: | 1629155023 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAROLINA PHYSICAL THERAPY SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 102 GREGOR MENDEL CIR | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296462315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642292663 | ||||||||
| FaxNumber: | 8642279510 | ||||||||
| Practice Location | |||||||||
| Address1: | 102 GREGOR MENDEL CIR | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296462315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642292663 | ||||||||
| FaxNumber: | 8642279510 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 01/22/2010 | ||||||||
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| AuthorizedOfficialLastName: | LUCAS | ||||||||
| AuthorizedOfficialFirstName: | PHYLLIS | ||||||||
| AuthorizedOfficialMiddleName: | LESLIE | ||||||||
| AuthorizedOfficialTitleorPosition: | LEAD PHYSICAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 8642292663 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | MS, PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | 4489 | SC | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | 8624 | 01 | SC | MEDICARE PTAN | OTHER | 000071507 | 05 | SC | MEDICAID | DN2576 | 01 | SC | RAILROAD MEDICARE GROUP PTAN | OTHER |