Provider Demographics
NPI:1720035462
Name:LIVE OAKS PHYSICAL THERAPY
Entity Type:Organization
Organization Name:LIVE OAKS PHYSICAL THERAPY
Other - Org Name:LIVE OAKS PHYSICAL THERAPY
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALLYSON
Authorized Official - Middle Name:GRAVES
Authorized Official - Last Name:BENSCH
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:843-717-2400
Mailing Address - Street 1:8084 E MAIN ST STE A
Mailing Address - Street 2:SUITE A
Mailing Address - City:RIDGELAND
Mailing Address - State:SC
Mailing Address - Zip Code:29936-8667
Mailing Address - Country:US
Mailing Address - Phone:843-717-2400
Mailing Address - Fax:843-717-2500
Practice Address - Street 1:8084 E MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:RIDGELAND
Practice Address - State:SC
Practice Address - Zip Code:29936-8599
Practice Address - Country:US
Practice Address - Phone:843-717-2400
Practice Address - Fax:843-717-2500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1369225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1369OtherLICENSE
SC426633Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER