Provider Demographics
NPI:1609940394
Name:LONG BAY REHAB, LLC
Entity Type:Organization
Organization Name:LONG BAY REHAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHELTON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:843-293-5610
Mailing Address - Street 1:PO BOX 220
Mailing Address - Street 2:
Mailing Address - City:CHAPIN
Mailing Address - State:SC
Mailing Address - Zip Code:29036-0220
Mailing Address - Country:US
Mailing Address - Phone:843-293-5610
Mailing Address - Fax:843-293-5690
Practice Address - Street 1:4871 SOCASTEE BLVD UNIT E
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-7252
Practice Address - Country:US
Practice Address - Phone:843-293-5610
Practice Address - Fax:843-293-5690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3584225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3715Medicaid
SC7672Medicare PIN