Provider Demographics
NPI:1467663534
Name:MACKENZIE, ALAN ROGER (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:ROGER
Last Name:MACKENZIE
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1413 HIGHWAY 17 S # 160
Mailing Address - Street 2:216 14 TH AVE S
Mailing Address - City:SURFSIDE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29575-6040
Mailing Address - Country:US
Mailing Address - Phone:843-650-3966
Mailing Address - Fax:
Practice Address - Street 1:3300 4TH AVE
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29527-6002
Practice Address - Country:US
Practice Address - Phone:843-248-5728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5045225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist