Provider Demographics
NPI:1396896254
Name:BERTOLUCCI, LAWRENCE EDWARD (PT , MA)
Entity type:Individual
Prefix:MR
First Name:LAWRENCE
Middle Name:EDWARD
Last Name:BERTOLUCCI
Suffix:
Gender:M
Credentials:PT , MA
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Mailing Address - Street 1:PO BOX 2397
Mailing Address - Street 2:
Mailing Address - City:PAWLEYS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29585-2397
Mailing Address - Country:US
Mailing Address - Phone:843-237-0200
Mailing Address - Fax:843-235-0242
Practice Address - Street 1:38 BUSINESS CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:PAWLEYS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29585
Practice Address - Country:US
Practice Address - Phone:843-235-0200
Practice Address - Fax:843-235-0242
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH9962225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ352947906Medicare PIN