Provider Demographics
NPI:1245241041
Name:IMAGINE PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:IMAGINE PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-375-5448
Mailing Address - Street 1:IMAGINE PHYSICAL THERAPY
Mailing Address - Street 2:5111 NORTH RHETT AVENUE
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29405-4219
Mailing Address - Country:US
Mailing Address - Phone:843-804-9033
Mailing Address - Fax:843-804-9020
Practice Address - Street 1:1125 LANDAU LANE
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29466-7300
Practice Address - Country:US
Practice Address - Phone:843-375-5448
Practice Address - Fax:843-628-6624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4419Medicaid