Basic Information
| Provider Information | |||||||||
| NPI: | 1548699366 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUPPLEMENTAL HEALTH CARE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SUPPLEMENTAL HEALTH CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3462 HIGHWAY 418 | ||||||||
| Address2: | |||||||||
| City: | FOUNTAIN INN | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296444829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8646409294 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4401 BELLE OAKS DR | ||||||||
| Address2: | SUITE 280 | ||||||||
| City: | N CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294058537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8665712700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2013 | ||||||||
| LastUpdateDate: | 11/02/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TRIPP | ||||||||
| AuthorizedOfficialFirstName: | KRISTIN | ||||||||
| AuthorizedOfficialMiddleName: | GARRETT | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 8646409294 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PT, DPT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | 6957 | SC | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.