Provider Demographics
NPI:1477937662
Name:IMAGINE PHYSICAL THERAPY OLD VILLAGE LLC
Entity Type:Organization
Organization Name:IMAGINE PHYSICAL THERAPY OLD VILLAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-804-9479
Mailing Address - Street 1:IMAGINE PHYSICAL THERAPY
Mailing Address - Street 2:5111 NORTH RHETT AVENUE
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29405-4219
Mailing Address - Country:US
Mailing Address - Phone:843-804-9077
Mailing Address - Fax:843-804-9020
Practice Address - Street 1:1304 ERCKMANN DR UNIT C
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-5536
Practice Address - Country:US
Practice Address - Phone:843-971-7668
Practice Address - Fax:843-971-7666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-17
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP6984Medicaid