Provider Demographics
NPI:1124414495
Name:SUNSHINE PEDIATRIC THERAPY OF SOUTH CAROLINA
Entity Type:Organization
Organization Name:SUNSHINE PEDIATRIC THERAPY OF SOUTH CAROLINA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:R
Authorized Official - Last Name:MCCULLOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:MS-PT
Authorized Official - Phone:770-256-9921
Mailing Address - Street 1:5 IVY LAWN PL
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-6522
Mailing Address - Country:US
Mailing Address - Phone:770-256-9921
Mailing Address - Fax:251-517-7216
Practice Address - Street 1:5 IVY LAWN PL
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-6522
Practice Address - Country:US
Practice Address - Phone:770-256-9921
Practice Address - Fax:251-517-7216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-13
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7626261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities