Provider Demographics
NPI:1457380123
Name:MARLBORO PHYSICAL THERAPY
Entity Type:Organization
Organization Name:MARLBORO PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PT
Authorized Official - Prefix:
Authorized Official - First Name:JUDIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:STO DOMINGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-454-9000
Mailing Address - Street 1:1021 CHERAW ST
Mailing Address - Street 2:
Mailing Address - City:BENNETTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29512-2422
Mailing Address - Country:US
Mailing Address - Phone:843-454-9000
Mailing Address - Fax:843-454-9001
Practice Address - Street 1:1021 CHERAW ST
Practice Address - Street 2:
Practice Address - City:BENNETTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29512-2422
Practice Address - Country:US
Practice Address - Phone:843-454-9000
Practice Address - Fax:843-454-9001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH1257Medicaid
SCTH1257Medicaid