Provider Demographics
NPI:1912098021
Name:ARDIS, SHANNON C (MPT)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:C
Last Name:ARDIS
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 2ND LOOP RD STE A
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29505-2815
Mailing Address - Country:US
Mailing Address - Phone:843-669-3665
Mailing Address - Fax:843-669-3706
Practice Address - Street 1:401 N MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:HEMINGWAY
Practice Address - State:SC
Practice Address - Zip Code:29554-9191
Practice Address - Country:US
Practice Address - Phone:843-558-4830
Practice Address - Fax:843-558-7752
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4136225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC426611Medicare PIN