1821292178 NPI number — CARLA B HAMILTON

Table of content: CARLA B HAMILTON (NPI 1821292178)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821292178 NPI number — CARLA B HAMILTON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAMILTON
Provider First Name:
CARLA
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1821292178
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3655 MITCHELL ST., BOX 690001
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LORIS
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29569-9601
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-716-7000
Provider Business Mailing Address Fax Number:
843-716-7093

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3655 MITCHELL ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LORIS
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29569-9601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-716-7000
Provider Business Practice Location Address Fax Number:
843-716-7093
Provider Enumeration Date:
06/12/2007

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: 367500000X , with the licence number:  AN0593 , 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: 400649 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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