Provider Demographics
NPI:1578693131
Name:DEFALCO, RICHARD ANTHONY (DPT, OCS, CSCS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:ANTHONY
Last Name:DEFALCO
Suffix:
Gender:M
Credentials:DPT, OCS, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2397
Mailing Address - Street 2:
Mailing Address - City:PAWLEYS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29585-2397
Mailing Address - Country:US
Mailing Address - Phone:843-235-0200
Mailing Address - Fax:843-235-0242
Practice Address - Street 1:1301 48TH AVE N
Practice Address - Street 2:SUITE D
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-5427
Practice Address - Country:US
Practice Address - Phone:843-839-1300
Practice Address - Fax:843-839-1320
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10205225100000X
NJ40QA01172100225100000X
SC6295225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP01046409OtherRAILROAD MEDICARE PTAN
SCP01245604OtherRAILROAD MEDICARE PRS 4 LLC
SCP00892030OtherRAILROAD MEDICARE PRS 3 LLC
SCTH2436Medicaid
SCP01046409OtherRAILROAD MEDICARE PTAN
SCQ37495C630Medicare PIN
SCP00892030OtherRAILROAD MEDICARE PRS 3 LLC
SCQ374959403Medicare PIN
NC250146Medicare PIN
SCTH2436Medicaid