Individual
KELLY MACK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PT
Contact information
Practice address
107 HOLLY CREEK DR, IRMO, SC 29063-8918
(803) 749-1625
Mailing address
107 HOLLY CREEK DR, IRMO, SC 29063-8918
Taxonomy
Speciality
Code
Description
License number
State
2251P0200X
Pediatric Physical Therapist
Primary
2278
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
THO443
—
SC
Enumeration date
08/23/2008
Last updated
08/23/2008
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