Provider Demographics
NPI:1366453003
Name:MONCKS CORNER PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:MONCKS CORNER PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:FRANCES
Authorized Official - Middle Name:P
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-899-5374
Mailing Address - Street 1:209 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MONCKS CORNER
Mailing Address - State:SC
Mailing Address - Zip Code:29461-2604
Mailing Address - Country:US
Mailing Address - Phone:843-899-5374
Mailing Address - Fax:843-899-5376
Practice Address - Street 1:209 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461-2604
Practice Address - Country:US
Practice Address - Phone:843-899-5374
Practice Address - Fax:843-899-5376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC767225100000X
SC1202225100000X
SC2237225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDA3658Medicare PIN
SC7388Medicare PIN