Provider Demographics
NPI:1396250049
Name:CORA SOUTH CAROLINA LLC
Entity type:Organization
Organization Name:CORA SOUTH CAROLINA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:C
Authorized Official - Last Name:ROUSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-221-6712
Mailing Address - Street 1:1110 SHAWNEE RD
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805-3529
Mailing Address - Country:US
Mailing Address - Phone:419-221-6720
Mailing Address - Fax:419-222-0507
Practice Address - Street 1:1110 SHAWNEE RD
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45805-3529
Practice Address - Country:US
Practice Address - Phone:419-221-6720
Practice Address - Fax:419-222-0507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-04
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation