1093741613 NPI number — MRS. NICOLE PERRIN KETCHIN PAC

Table of content: MRS. NICOLE PERRIN KETCHIN PAC (NPI 1093741613)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093741613 NPI number — MRS. NICOLE PERRIN KETCHIN PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KETCHIN
Provider First Name:
NICOLE
Provider Middle Name:
PERRIN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PAC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093741613
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/20/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 751649
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28275-1649
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-789-1620
Provider Business Mailing Address Fax Number:
843-724-2440

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
180 WINGO WAY
Provider Second Line Business Practice Location Address:
SUITE 307
Provider Business Practice Location Address City Name:
MT PLEASANT
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29464-1810
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-884-1777
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  1073 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0363PA , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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