Provider Demographics
NPI:1285798231
Name:ELLIS PHYSICAL THERAPY ASSOCIATES, INC
Entity type:Organization
Organization Name:ELLIS PHYSICAL THERAPY ASSOCIATES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:803-783-0684
Mailing Address - Street 1:PO BOX 11400
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29211-1400
Mailing Address - Country:US
Mailing Address - Phone:803-783-0684
Mailing Address - Fax:803-783-1147
Practice Address - Street 1:3937 SUNSET BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169
Practice Address - Country:US
Practice Address - Phone:803-794-2213
Practice Address - Fax:803-791-5284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC285225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC42-6542Medicare ID - Type Unspecified