Provider Demographics
NPI:1174774186
Name:PALMETTO REHABILITATION SPECIALISTS
Entity type:Organization
Organization Name:PALMETTO REHABILITATION SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-802-5855
Mailing Address - Street 1:105 BEN CASEY DR
Mailing Address - Street 2:SUITE 127
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708-8561
Mailing Address - Country:US
Mailing Address - Phone:803-802-5855
Mailing Address - Fax:803-802-5869
Practice Address - Street 1:134 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-1178
Practice Address - Country:US
Practice Address - Phone:803-329-4685
Practice Address - Fax:803-329-4683
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-08
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC225X00000X, 225XH1200X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHandGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4586Medicaid
SCGP4586Medicaid