Provider Demographics
NPI:1023067014
Name:SOUTHERN STATES PHYSICAL MEDICINE AND REHABILITATION CENTER
Entity type:Organization
Organization Name:SOUTHERN STATES PHYSICAL MEDICINE AND REHABILITATION CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAM
Authorized Official - Middle Name:
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-283-8442
Mailing Address - Street 1:1002 N WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:SC
Mailing Address - Zip Code:29720-1966
Mailing Address - Country:US
Mailing Address - Phone:803-283-8442
Mailing Address - Fax:803-286-4604
Practice Address - Street 1:1002 N WOODLAND DR
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:SC
Practice Address - Zip Code:29720-1966
Practice Address - Country:US
Practice Address - Phone:803-283-8442
Practice Address - Fax:803-286-4604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2158111N00000X
SC5224225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGCH200Medicaid
SCGCH200Medicaid