Provider Demographics
NPI:1497229124
Name:EVANS, FRED L III (PTA)
Entity Type:Individual
Prefix:MR
First Name:FRED
Middle Name:L
Last Name:EVANS
Suffix:III
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O BOX 1116
Mailing Address - Street 2:
Mailing Address - City:LAMAR
Mailing Address - State:SC
Mailing Address - Zip Code:29069
Mailing Address - Country:US
Mailing Address - Phone:843-616-4488
Mailing Address - Fax:
Practice Address - Street 1:2439 WILLWOOD DR.
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501
Practice Address - Country:US
Practice Address - Phone:843-777-2196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3241225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant