Provider Demographics
NPI:1285024836
Name:SOUTHERN STATES PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:SOUTHERN STATES PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:FAKER
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:704-578-0641
Mailing Address - Street 1:2670 MILLS PARK DR
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-8599
Mailing Address - Country:US
Mailing Address - Phone:803-324-3745
Mailing Address - Fax:803-324-9845
Practice Address - Street 1:106A WOODLAND DR
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:SC
Practice Address - Zip Code:29720-4707
Practice Address - Country:US
Practice Address - Phone:803-283-8442
Practice Address - Fax:803-286-4604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-03
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4533225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC13501810OtherCAQH