Provider Demographics
NPI:1346859881
Name:WAVE PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:WAVE PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:BLACKWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:843-437-8184
Mailing Address - Street 1:211 OAKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-9701
Mailing Address - Country:US
Mailing Address - Phone:843-437-8184
Mailing Address - Fax:
Practice Address - Street 1:211 OAKWOOD DR
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-9701
Practice Address - Country:US
Practice Address - Phone:843-437-8184
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-30
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty