Provider Demographics
NPI:1518225606
Name:VICKERS, GEOFFREY (PTA)
Entity Type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:
Last Name:VICKERS
Suffix:
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 1:1002 N WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:SC
Mailing Address - Zip Code:29720-1966
Mailing Address - Country:US
Mailing Address - Phone:803-324-3745
Mailing Address - Fax:
Practice Address - Street 1:1002 N WOODLAND DR
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:SC
Practice Address - Zip Code:29720-1966
Practice Address - Country:US
Practice Address - Phone:803-324-3745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-26
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2234225200000X
NC3977225200000X
CAAT5834225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant