Provider Demographics
NPI:1356995211
Name:OKATIE PHYSICAL THERAPY AND SPORTS MEDICINE
Entity type:Organization
Organization Name:OKATIE PHYSICAL THERAPY AND SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:J. ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:GAVIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-645-2668
Mailing Address - Street 1:15 MOSS CREEK VLG
Mailing Address - Street 2:
Mailing Address - City:HILTON HEAD
Mailing Address - State:SC
Mailing Address - Zip Code:29926-1105
Mailing Address - Country:US
Mailing Address - Phone:843-681-5077
Mailing Address - Fax:
Practice Address - Street 1:149 RIVERWALK BLVD STE 3
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:SC
Practice Address - Zip Code:29936-8191
Practice Address - Country:US
Practice Address - Phone:843-645-2668
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-30
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Multi-Specialty