Provider Demographics
NPI:1639593866
Name:MIMS, TAMMIE (PT)
Entity Type:Individual
Prefix:MRS
First Name:TAMMIE
Middle Name:
Last Name:MIMS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 N MAIN ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-6414
Mailing Address - Country:US
Mailing Address - Phone:803-348-4744
Mailing Address - Fax:803-735-8047
Practice Address - Street 1:3800 N MAIN ST
Practice Address - Street 2:SUITE E
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6414
Practice Address - Country:US
Practice Address - Phone:803-348-4744
Practice Address - Fax:803-735-8047
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-07
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2479225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC7263Medicare UPIN