Provider Demographics
NPI:1649634593
Name:CHARLESTON PEDIATRIC REHABILITATION
Entity type:Organization
Organization Name:CHARLESTON PEDIATRIC REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:LINDSAY
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-569-3033
Mailing Address - Street 1:2070 NORTHBROOK BLVD
Mailing Address - Street 2:SUITE B-4
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9252
Mailing Address - Country:US
Mailing Address - Phone:843-569-3033
Mailing Address - Fax:843-569-6820
Practice Address - Street 1:2070 NORTHBROOK BLVD
Practice Address - Street 2:SUITE B-4
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9252
Practice Address - Country:US
Practice Address - Phone:843-569-3033
Practice Address - Fax:843-569-6820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-07
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty