Provider Demographics
NPI:1316097702
Name:OMNI PHYSICAL THERAPY INC
Entity type:Organization
Organization Name:OMNI PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:KEZIAH
Authorized Official - Last Name:SHUMATE
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:843-409-1620
Mailing Address - Street 1:1647 RUBY RD
Mailing Address - Street 2:
Mailing Address - City:HARTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29550-2407
Mailing Address - Country:US
Mailing Address - Phone:843-409-1620
Mailing Address - Fax:
Practice Address - Street 1:126 N MACARTHUR AVE
Practice Address - Street 2:
Practice Address - City:DILLON
Practice Address - State:SC
Practice Address - Zip Code:29536-3434
Practice Address - Country:US
Practice Address - Phone:843-774-7462
Practice Address - Fax:843-841-2482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4705225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH1381Medicaid