Provider Demographics
NPI:1407935596
Name:SAMUEL CHIROPRACTIC PA
Entity Type:Organization
Organization Name:SAMUEL CHIROPRACTIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR, OT
Authorized Official - Prefix:DR
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:K
Authorized Official - Last Name:SAMUEL
Authorized Official - Suffix:
Authorized Official - Credentials:DC,CCEP,DABCI,BS,MS,
Authorized Official - Phone:803-252-4966
Mailing Address - Street 1:2757 LAUREL ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-2037
Mailing Address - Country:US
Mailing Address - Phone:803-252-4966
Mailing Address - Fax:803-252-1984
Practice Address - Street 1:2757 LAUREL ST
Practice Address - Street 2:SUITE 4
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2037
Practice Address - Country:US
Practice Address - Phone:803-252-4966
Practice Address - Fax:803-252-1984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH1561Medicaid
SCCH1561Medicaid
SCU32829Medicare UPIN