Provider Demographics
NPI:1538580733
Name:BATES, MARDELL
Entity type:Individual
Prefix:
First Name:MARDELL
Middle Name:
Last Name:BATES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4807 BUTTERCUP WAY
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29485-8970
Mailing Address - Country:US
Mailing Address - Phone:843-412-7713
Mailing Address - Fax:
Practice Address - Street 1:412 DRIVE IN LN
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461-3160
Practice Address - Country:US
Practice Address - Phone:843-761-6732
Practice Address - Fax:843-761-6734
Is Sole Proprietor?:No
Enumeration Date:2013-12-16
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5101225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist