Basic Information
| Provider Information | |||||||||
| NPI: | 1386150613 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PIVOTAL INJURY AND REHAB INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2632 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 290712632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032189886 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2627 MILLWOOD AVE STE C | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292051273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032189886 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2017 | ||||||||
| LastUpdateDate: | 01/03/2018 | ||||||||
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| AuthorizedOfficialLastName: | FARMER | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8032544699 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | N | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor | 208100000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.