Healthcare Provider Details

I. General information

NPI: 1174718738
Provider Name (Legal Business Name): KELLY BLAKE CANTU PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY BLAKE RYDER PA-C

II. Dates (important events)

Enumeration Date: 09/07/2007
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 CENTER POINT RD STE 2360
COLUMBIA SC
29210-5826
US

IV. Provider business mailing address

2000 CENTER POINT RD STE 2360
COLUMBIA SC
29210-5826
US

V. Phone/Fax

Practice location:
  • Phone: 803-233-5500
  • Fax: 803-258-6395
Mailing address:
  • Phone: 803-233-5500
  • Fax: 803-258-6395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number1770252017
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: