Provider Demographics
NPI:1164404711
Name:COLUMBIA REHABILITATION CLINIC
Entity Type:Organization
Organization Name:COLUMBIA REHABILITATION CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:FILLER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:803-799-7007
Mailing Address - Street 1:2362 TWO NOTCH RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-2257
Mailing Address - Country:US
Mailing Address - Phone:803-799-7007
Mailing Address - Fax:803-256-8410
Practice Address - Street 1:2362 TWO NOTCH RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2257
Practice Address - Country:US
Practice Address - Phone:803-799-7007
Practice Address - Fax:803-256-8410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-18
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC=========OtherBCBS FEDERAL
SC=========OtherRPN
SC=========OtherAETNA
SC=========OtherBCBS OF SC
SC=========OtherTRICARE
SC=========OtherMEDICARE
SC=========OtherBLUE CHOICE
SC=========OtherMETRA HEALTH RRB MEDICARE
SC=========OtherCAROLINA CARE PLAN
SC=========OtherHUMANA
SC=========OtherSC MEDICAID
SC=========OtherBCBS PPO