Provider Demographics
NPI:1114943099
Name:SOUTHERN STATES PHYSICAL MEDICINE AND REHABILIATION CENTER
Entity Type:Organization
Organization Name:SOUTHERN STATES PHYSICAL MEDICINE AND REHABILIATION CENTER
Other - Org Name:SOUTHERN STATES FAMILY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:GEADA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-283-8442
Mailing Address - Street 1:1002 N WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:SC
Mailing Address - Zip Code:29720-1966
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8763 CHARLOTTE HWY
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715-7589
Practice Address - Country:US
Practice Address - Phone:803-548-8452
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2158111N00000X
SC3884225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC=========-003OtherBCBS & STATE
SC=========-002OtherBCSB AND BCBS STATE
SC=========-003OtherBCBS & STATE