Healthcare Provider Details

I. General information

NPI: 1982189718
Provider Name (Legal Business Name): CHARLESTON PEDIATRIC REHABILITATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2018
Last Update Date: 09/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1407 ASHLEY RIVER RD
CHARLESTON SC
29407-5305
US

IV. Provider business mailing address

2070 NORTHBROOK BLVD STE B4
NORTH CHARLESTON SC
29406-9254
US

V. Phone/Fax

Practice location:
  • Phone: 843-364-5437
  • Fax:
Mailing address:
  • Phone: 843-364-5437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL COYLE
Title or Position: OWNER
Credential:
Phone: 843-769-0663