Provider Demographics
NPI:1578746764
Name:CAROLINA KIDS THERAPEUTIC INTERVENTIONS, LLC
Entity Type:Organization
Organization Name:CAROLINA KIDS THERAPEUTIC INTERVENTIONS, LLC
Other - Org Name:CAROLINA KIDS
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTINE
Authorized Official - Middle Name:W
Authorized Official - Last Name:HAYNES
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:803-767-9737
Mailing Address - Street 1:PO BOX 225
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29202-0225
Mailing Address - Country:US
Mailing Address - Phone:803-767-9737
Mailing Address - Fax:803-749-6932
Practice Address - Street 1:454 BOOKMAN MILL RD
Practice Address - Street 2:
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063-7946
Practice Address - Country:US
Practice Address - Phone:803-767-9737
Practice Address - Fax:803-749-6932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2009-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC54062251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Single Specialty