Basic Information
| Provider Information | |||||||||
| NPI: | 1639102312 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LOW COUNTRY PHYSICAL THERAPY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2586 HIGHWAY 17 SOUTH | ||||||||
| Address2: | UNIT C&D | ||||||||
| City: | GARDEN CITY BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295766605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436516565 | ||||||||
| FaxNumber: | 8436516575 | ||||||||
| Practice Location | |||||||||
| Address1: | 2586 S HIGHWAY 17 UNIT C&D | ||||||||
| Address2: | |||||||||
| City: | MURRELLS INLET | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295766605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436516565 | ||||||||
| FaxNumber: | 8436516575 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 03/12/2020 | ||||||||
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| AuthorizedOfficialLastName: | SHOUP | ||||||||
| AuthorizedOfficialFirstName: | DEBBIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | INSURANCE SPECIALIST/CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 8436516565 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | GP4329 | 05 | SC | MEDICAID |