Provider Demographics
NPI:1013931799
Name:SAMUEL, VIRGINIA KAYE (DC)
Entity Type:Individual
Prefix:DR
First Name:VIRGINIA
Middle Name:KAYE
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1561111NI0900X, 111N00000X
SC3722225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NI0900XChiropractic ProvidersChiropractorInternist
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH1561Medicaid
SCU328290281Medicare UPIN
SCCH1561Medicaid