Healthcare Provider Details

I. General information

NPI: 1104892637
Provider Name (Legal Business Name): CHARLES BLAKE PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2006
Last Update Date: 03/18/2025
Certification Date: 03/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MONCRIEF ARMY HEALTH CLINIC 4500 8TH DIVISION DRIVE
COLUMBIA SC
29207
US

IV. Provider business mailing address

MONCRIEF ARMY HEALTH CLINIC 4500 8TH DIVISION DRIVE
COLUMBIA SC
29207
US

V. Phone/Fax

Practice location:
  • Phone: 803-751-7183
  • Fax:
Mailing address:
  • Phone: 803-751-7183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number420820
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: