Healthcare Provider Details

I. General information

NPI: 1336891951
Provider Name (Legal Business Name): EMMANUEL MEDICAL & REHAB, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2022
Last Update Date: 01/25/2022
Certification Date: 01/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1812 HAMPTON ST STE A
COLUMBIA SC
29201-3580
US

IV. Provider business mailing address

1812 HAMPTON ST STE A
COLUMBIA SC
29201-3580
US

V. Phone/Fax

Practice location:
  • Phone: 864-205-6137
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: RANDY GOINGS
Title or Position: OWNER
Credential:
Phone: 864-205-6137