Provider Demographics
NPI:1043910441
Name:HOMEGROWN PEDIATRIC THERAPIES LLC
Entity Type:Organization
Organization Name:HOMEGROWN PEDIATRIC THERAPIES LLC
Other - Org Name:HOMEGROWN PT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ROSS
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:208-613-7361
Mailing Address - Street 1:211 SQUIRE POPE RD
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29486-6999
Mailing Address - Country:US
Mailing Address - Phone:208-613-7361
Mailing Address - Fax:843-892-8444
Practice Address - Street 1:211 SQUIRE POPE RD
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29486-6999
Practice Address - Country:US
Practice Address - Phone:208-613-7361
Practice Address - Fax:843-892-8444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-06
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty