Provider Demographics
NPI:1457960726
Name:OREILLY, JERRY SCOTT (PTA)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:SCOTT
Last Name:OREILLY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:573 PLYMOUTH PASS DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-7028
Mailing Address - Country:US
Mailing Address - Phone:803-960-7581
Mailing Address - Fax:
Practice Address - Street 1:100 DREHER RD
Practice Address - Street 2:SUITE 100
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169
Practice Address - Country:US
Practice Address - Phone:803-525-8070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-23
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1180225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant