Provider Demographics
NPI:1245772755
Name:ACKER PHYSICAL THERAPY
Entity Type:Organization
Organization Name:ACKER PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING/CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:DANESE
Authorized Official - Last Name:LOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-667-1819
Mailing Address - Street 1:144 LEISURE LN STE 100
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-4156
Mailing Address - Country:US
Mailing Address - Phone:803-888-6125
Mailing Address - Fax:803-888-6085
Practice Address - Street 1:144 LEISURE LN STE 100
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29210-4156
Practice Address - Country:US
Practice Address - Phone:803-331-3682
Practice Address - Fax:803-791-3862
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-15
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1580261QP2000X
SC5266261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1528364734OtherPERSONAL NPI
SCQ363230281Medicare PIN