Provider Demographics
NPI:1255583605
Name:FAIRCLOTH, ELIZABETH RYAN (PT)
Entity type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:RYAN
Last Name:FAIRCLOTH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:943 PINE LOG RD
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29803-7330
Mailing Address - Country:US
Mailing Address - Phone:803-649-9797
Mailing Address - Fax:803-642-2759
Practice Address - Street 1:943 PINE LOG RD
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29803
Practice Address - Country:US
Practice Address - Phone:803-649-9797
Practice Address - Fax:803-642-2759
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-16
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5352225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ351679262Medicare UPIN