Provider Demographics
NPI:1760806160
Name:MYRTLE BEACH PHYSICAL MEDICINE & REHAB, LLC
Entity Type:Organization
Organization Name:MYRTLE BEACH PHYSICAL MEDICINE & REHAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:LUCKIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-444-9355
Mailing Address - Street 1:4736 17 BYPASS SOUTH
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29588
Mailing Address - Country:US
Mailing Address - Phone:843-444-9355
Mailing Address - Fax:843-294-0019
Practice Address - Street 1:4736 17 BYPASS SOUTH
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588
Practice Address - Country:US
Practice Address - Phone:843-444-9355
Practice Address - Fax:843-294-0019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-06
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty