Provider Demographics
NPI:1861678534
Name:PATTISONS D R E A M ACADEMY
Entity Type:Organization
Organization Name:PATTISONS D R E A M ACADEMY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:GANCI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-402-7850
Mailing Address - Street 1:PO BOX 80426
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29416-0426
Mailing Address - Country:US
Mailing Address - Phone:843-402-7850
Mailing Address - Fax:843-402-7851
Practice Address - Street 1:721 WAPPOO RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-5861
Practice Address - Country:US
Practice Address - Phone:843-402-7850
Practice Address - Fax:843-402-7850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-12
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4825-1861678535Medicaid