Healthcare Provider Details

I. General information

NPI: 1457170110
Provider Name (Legal Business Name): BRANDAN LEE HOSTAR PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2024
Last Update Date: 10/08/2024
Certification Date: 10/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 FOREST DR STE B101
COLUMBIA SC
29204-4146
US

IV. Provider business mailing address

150 HIGHLAND CENTER DR STE B
COLUMBIA SC
29203-9247
US

V. Phone/Fax

Practice location:
  • Phone: 803-764-2363
  • Fax: 803-550-9389
Mailing address:
  • Phone: 803-699-9775
  • Fax: 803-699-8099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: