Provider Demographics
NPI:1326467176
Name:IMAGINE PHYSICAL THERAPY
Entity Type:Organization
Organization Name:IMAGINE PHYSICAL THERAPY
Other - Org Name:IMAGINE PHYSICAL THERAPY, WESLEY DRIVE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:MART
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:843-375-5448
Mailing Address - Street 1:3301 STOCKDALE ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29466-7125
Mailing Address - Country:US
Mailing Address - Phone:843-375-5448
Mailing Address - Fax:843-628-6624
Practice Address - Street 1:615 WESLEY DR
Practice Address - Street 2:SUITE 110
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-7204
Practice Address - Country:US
Practice Address - Phone:843-554-2323
Practice Address - Fax:843-763-8124
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IMAGINE PHYSICAL THERAPY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-04-09
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy