Provider Demographics
NPI:1104859610
Name:QUEEN, BRANTON RICE (PT)
Entity Type:Individual
Prefix:
First Name:BRANTON
Middle Name:RICE
Last Name:QUEEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 VILLAGE CENTER BLVD STE 140
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-6706
Mailing Address - Country:US
Mailing Address - Phone:843-353-3460
Mailing Address - Fax:843-353-3461
Practice Address - Street 1:210 VILLAGE CENTER BLVD STE 100
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-6706
Practice Address - Country:US
Practice Address - Phone:843-353-3460
Practice Address - Fax:843-353-3461
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT6042225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist