Provider Demographics
NPI:1932276805
Name:CHARLESTON PEDIATRIC REHABILITATION LLC
Entity Type:Organization
Organization Name:CHARLESTON PEDIATRIC REHABILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:COYLE
Authorized Official - Suffix:
Authorized Official - Credentials:OTRL
Authorized Official - Phone:843-769-0663
Mailing Address - Street 1:1407 ASHLEY RIVER RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-5305
Mailing Address - Country:US
Mailing Address - Phone:843-769-0663
Mailing Address - Fax:843-769-0556
Practice Address - Street 1:1407 ASHLEY RIVER RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-5305
Practice Address - Country:US
Practice Address - Phone:843-769-0663
Practice Address - Fax:843-769-0556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Not Answered235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3373Medicaid