Provider Demographics
NPI:1851129977
Name:TIDAL CREEK PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:TIDAL CREEK PHYSICAL THERAPY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PTA
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:843-379-3991
Mailing Address - Street 1:11 ROBERT SMALLS PKWY
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29906-4202
Mailing Address - Country:US
Mailing Address - Phone:843-379-3991
Mailing Address - Fax:843-582-0283
Practice Address - Street 1:95 SEA ISLAND PKWY STE 103
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29907-1499
Practice Address - Country:US
Practice Address - Phone:843-379-3991
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TIDAL CREEK PHYSICAL, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-07-22
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy