Provider Demographics
NPI:1306074885
Name:RIVERTOWN LYMPHEDEMA CLINIC AND REHAB, LLC
Entity type:Organization
Organization Name:RIVERTOWN LYMPHEDEMA CLINIC AND REHAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:KINCHELOE
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L, CLT
Authorized Official - Phone:843-742-5701
Mailing Address - Street 1:100 PRATHER PARK DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29588-7910
Mailing Address - Country:US
Mailing Address - Phone:843-742-5701
Mailing Address - Fax:843-742-5704
Practice Address - Street 1:100 PRATHER PARK DR
Practice Address - Street 2:SUITE A
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-7910
Practice Address - Country:US
Practice Address - Phone:843-742-5701
Practice Address - Fax:843-742-5704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-23
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy