Basic Information
| Provider Information | |||||||||
| NPI: | 1932276102 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | PHILLIP | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 219 SOUTHERN ROAD | ||||||||
| Address2: | |||||||||
| City: | BELTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296278727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642432429 | ||||||||
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| Practice Location | |||||||||
| Address1: | GREENWOOD SPORTS AND INDUSTRIAL REHAB | ||||||||
| Address2: | 1602 SPRING STREET | ||||||||
| City: | GREENWOOD | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642299000 | ||||||||
| FaxNumber: | 8642295474 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | SC - # 13 | SC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.