Provider Demographics
NPI:1467657783
Name:BALLENTINE REHABILITATION & WELLNESS
Entity Type:Organization
Organization Name:BALLENTINE REHABILITATION & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:AUGUSTUS
Authorized Official - Last Name:RESS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:803-732-0815
Mailing Address - Street 1:PO BOX 302
Mailing Address - Street 2:
Mailing Address - City:BALLENTINE
Mailing Address - State:SC
Mailing Address - Zip Code:29002-0302
Mailing Address - Country:US
Mailing Address - Phone:803-732-0815
Mailing Address - Fax:
Practice Address - Street 1:1000 MARINA RD
Practice Address - Street 2:SUITE C
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063
Practice Address - Country:US
Practice Address - Phone:803-732-0815
Practice Address - Fax:803-732-0816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC630225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty