Provider Demographics
NPI:1972961910
Name:TIDELANDS REHABILITATION GROUP LLC
Entity Type:Organization
Organization Name:TIDELANDS REHABILITATION GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINA
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:NORENA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-870-8822
Mailing Address - Street 1:4000 FABER PLACE DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29405-8585
Mailing Address - Country:US
Mailing Address - Phone:843-870-8822
Mailing Address - Fax:843-388-0349
Practice Address - Street 1:4000 FABER PLACE DR
Practice Address - Street 2:SUITE 300
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29405-8585
Practice Address - Country:US
Practice Address - Phone:843-870-8822
Practice Address - Fax:843-388-0349
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-05
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC0000261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP5849Medicaid