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NPI Code Detail

MEDICARE: KELLY BLAKE CANTU PA-C

MEDICARE: KELLY BLAKE CANTU PA-C
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12081P2900XPain Medicine (Physical Medicine & Rehabilitation) Physician1770252017SC

General Provider Information

NPI Number : 1174718738
Entity Type Code : Individual
Provider Name (Legal Business Name) : KELLY BLAKE CANTU PA-C
Provider Business Mailing Address
First Line : 2000 CENTER POINT RD STE 2360
Second Line :
City : COLUMBIA
State : SC
Zip : 29210-5826
Country : US
Telephone Number : 803-233-5500
Fax Number : 803-258-6395
Provider Business Practice Location Address
First Line : 2000 CENTER POINT RD STE 2360
Second Line :
City : COLUMBIA
State : SC
Zip : 29210-5826
Country : US
Telephone Number : 803-233-5500
Fax Number : 803-258-6395
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/07/2007
Last Update Date : 10/22/2024

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Directions to “ KELLY BLAKE CANTU PA-C” Practice Location

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