Provider Demographics
NPI:1194773945
Name:SUMTER PHYSICAL THERAPY CLINIC, LLC
Entity type:Organization
Organization Name:SUMTER PHYSICAL THERAPY CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:LOWE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:843-662-1234
Mailing Address - Street 1:507 W CHEVES ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-4449
Mailing Address - Country:US
Mailing Address - Phone:843-662-1234
Mailing Address - Fax:843-669-7144
Practice Address - Street 1:1185 WILSON HALL RD
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-1842
Practice Address - Country:US
Practice Address - Phone:803-469-3213
Practice Address - Fax:803-469-3233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1010723225100000X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2145Medicaid
SCGP2145Medicaid