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General NPI Number Information
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NPI Number | 1982189718
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Entity Type | Organization
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Legal Business Name | CHARLESTON PEDIATRIC REHABILITATION LLC
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Dates
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Enumeration Date | 09/27/2018
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Last Update Date | 09/27/2018
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Provider Practice Location Address
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Address Line | 1407 ASHLEY RIVER RD
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City | CHARLESTON
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State | SC
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Zip | 29407-5305
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Country | US
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Telephone | 843-364-5437
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Fax |
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Provider Business Mailing Address
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Address Line | 2070 NORTHBROOK BLVD STE B4
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City | NORTH CHARLESTON
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State | SC
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Zip | 29406-9254
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Country | US
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Telephone | 843-364-5437
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MICHAEL COYLE
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Credential |
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Telephone | 843-769-0663
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number |
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License Number State |
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