Provider Demographics
NPI:1225160088
Name:MIMS, CHRISTOPHER S (PT)
Entity Type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:S
Last Name:MIMS
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 1:4100 MAIN ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-5800
Mailing Address - Country:US
Mailing Address - Phone:803-735-8047
Mailing Address - Fax:
Practice Address - Street 1:4100 MAIN ST
Practice Address - Street 2:SUITE 204
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-5800
Practice Address - Country:US
Practice Address - Phone:803-735-8047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2582225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC571096863OtherTAX ID
SCTH0474Medicaid