Provider Demographics
NPI:1194960872
Name:INDIGO THERAPY SPECIALISTS, LLC
Entity type:Organization
Organization Name:INDIGO THERAPY SPECIALISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR OF PHYSICAL THERAPY
Authorized Official - Prefix:MR
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:J
Authorized Official - Last Name:KLIXBULL
Authorized Official - Suffix:
Authorized Official - Credentials:DPT, CSCS
Authorized Official - Phone:843-357-4039
Mailing Address - Street 1:PO BOX 1795
Mailing Address - Street 2:
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576-1795
Mailing Address - Country:US
Mailing Address - Phone:843-357-4039
Mailing Address - Fax:843-357-4227
Practice Address - Street 1:11931 PLAZA DR
Practice Address - Street 2:
Practice Address - City:MURRELLS INLET
Practice Address - State:SC
Practice Address - Zip Code:29576-9356
Practice Address - Country:US
Practice Address - Phone:843-357-4039
Practice Address - Fax:843-357-4227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-09
Last Update Date:2009-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5347225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty