Provider Demographics
NPI:1952767519
Name:CORA SOUTH CAROLINA LLC
Entity type:Organization
Organization Name:CORA SOUTH CAROLINA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KRZYMINSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-221-6717
Mailing Address - Street 1:PO BOX 150
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45802-0150
Mailing Address - Country:US
Mailing Address - Phone:419-221-6717
Mailing Address - Fax:419-222-0507
Practice Address - Street 1:536 HIGHWAY 17 N
Practice Address - Street 2:
Practice Address - City:NORTH MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29582-2904
Practice Address - Country:US
Practice Address - Phone:843-417-1042
Practice Address - Fax:843-249-5740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-12
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP7414Medicaid
SC426641Medicare Oscar/Certification