Basic Information
| Provider Information | |||||||||
| NPI: | 1669457859 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREENVILLE PROAXIS THERAPY, LLC | ||||||||
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| OtherOrganizationName: | ATI PHYSICAL THERAPY OF GREENVILLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962223 | ||||||||
| FaxNumber: | 6307599510 | ||||||||
| Practice Location | |||||||||
| Address1: | 103 N MAIN ST | ||||||||
| Address2: | STE 99 | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296012796 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645285728 | ||||||||
| FaxNumber: | 8645285729 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2005 | ||||||||
| LastUpdateDate: | 11/18/2015 | ||||||||
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| AuthorizedOfficialLastName: | MCGIVERN | ||||||||
| AuthorizedOfficialFirstName: | LYNN | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF COMPLIANCE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6302962222 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | DD4407 | 01 | SC | MEDICARE RAILROAD | OTHER | GP4143 | 05 | SC | MEDICAID |