Provider Demographics
NPI:1568490571
Name:VIVATEK DISC REHAB CENTER LLC
Entity Type:Organization
Organization Name:VIVATEK DISC REHAB CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:843-249-5100
Mailing Address - Street 1:119 PINNACLE PL
Mailing Address - Street 2:SUITE B
Mailing Address - City:LITTLE RIVER
Mailing Address - State:SC
Mailing Address - Zip Code:29566-7218
Mailing Address - Country:US
Mailing Address - Phone:843-249-5100
Mailing Address - Fax:
Practice Address - Street 1:119 PINNACLE PL
Practice Address - Street 2:SUITE B
Practice Address - City:LITTLE RIVER
Practice Address - State:SC
Practice Address - Zip Code:29566-7218
Practice Address - Country:US
Practice Address - Phone:843-249-5100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1151111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH1151Medicaid
SCT326948512OtherMEDICARE PTAN
SCT32694Medicare UPIN
SCT32694Medicare UPIN
SCT326940281Medicare ID - Type Unspecified