Provider Demographics
NPI:1801341946
Name:GORETOY, EDUARD VIKTOROVICH (PTA)
Entity type:Individual
Prefix:
First Name:EDUARD
Middle Name:VIKTOROVICH
Last Name:GORETOY
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 1:100 DUNCAN HEIGHTS RD
Mailing Address - Street 2:
Mailing Address - City:DUNCAN
Mailing Address - State:SC
Mailing Address - Zip Code:29334-9332
Mailing Address - Country:US
Mailing Address - Phone:864-542-3809
Mailing Address - Fax:
Practice Address - Street 1:100 DUNCAN HEIGHTS RD
Practice Address - Street 2:
Practice Address - City:DUNCAN
Practice Address - State:SC
Practice Address - Zip Code:29334-9332
Practice Address - Country:US
Practice Address - Phone:864-542-3809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-18
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2716225200000X
AZ12350A225200000X
TX2119263225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant