Provider Demographics
NPI:1194186213
Name:SUMMERVILLE PHYSICAL THERAPY & BALANCE REHABILITATION FOR ADULTS, LLC
Entity Type:Organization
Organization Name:SUMMERVILLE PHYSICAL THERAPY & BALANCE REHABILITATION FOR ADULTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:P
Authorized Official - Last Name:BRUNGO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:843-209-6375
Mailing Address - Street 1:679 ORANGEBURG ROAD
Mailing Address - Street 2:SUITE D
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483
Mailing Address - Country:US
Mailing Address - Phone:843-209-6375
Mailing Address - Fax:
Practice Address - Street 1:679 ORANGEBURG ROAD
Practice Address - Street 2:SUITE D
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483
Practice Address - Country:US
Practice Address - Phone:843-209-6375
Practice Address - Fax:843-225-0348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-17
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4850225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty