Provider Demographics
NPI:1225069040
Name:PEE DEE PHYSICAL THERAPY, INC.
Entity Type:Organization
Organization Name:PEE DEE PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:KIRBY
Authorized Official - Last Name:WALTER
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:843-374-7378
Mailing Address - Street 1:PO BOX 608
Mailing Address - Street 2:414 WEST MAIN ST
Mailing Address - City:LAKE CITY
Mailing Address - State:SC
Mailing Address - Zip Code:29560
Mailing Address - Country:US
Mailing Address - Phone:843-374-7378
Mailing Address - Fax:843-374-7379
Practice Address - Street 1:414 WEST MAIN ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:SC
Practice Address - Zip Code:29560
Practice Address - Country:US
Practice Address - Phone:843-374-7378
Practice Address - Fax:843-374-7379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3314Medicaid
SCGP3314Medicaid