Provider Demographics
NPI:1033518766
Name:IMAGINE PHYSICAL THERAPY NORTH RHETT LLC
Entity Type:Organization
Organization Name:IMAGINE PHYSICAL THERAPY NORTH RHETT LLC
Other - Org Name:IMAGINE PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-804-9479
Mailing Address - Street 1:5111 N RHETT AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29405-4219
Mailing Address - Country:US
Mailing Address - Phone:843-804-9077
Mailing Address - Fax:843-628-6624
Practice Address - Street 1:5111 N RHETT AVE
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29405-4219
Practice Address - Country:US
Practice Address - Phone:843-375-5448
Practice Address - Fax:843-628-6624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-19
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7041261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP6702Medicaid