1306118583 NPI number — INDIAN LAND PEDIATRICS, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306118583 NPI number — INDIAN LAND PEDIATRICS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDIAN LAND PEDIATRICS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1306118583
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/27/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7580 CHARLOTTE HWY
Provider Second Line Business Mailing Address:
SUITE 1000
Provider Business Mailing Address City Name:
FORT MILL
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29707-7801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-396-1090
Provider Business Mailing Address Fax Number:
803-396-1091

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7580 CHARLOTTE HWY
Provider Second Line Business Practice Location Address:
SUITE 1000
Provider Business Practice Location Address City Name:
FORT MILL
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29707-7801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-396-1090
Provider Business Practice Location Address Fax Number:
803-396-1091
Provider Enumeration Date:
02/02/2012

Additional Information

Authorized Official

Authorized Official Last Name:
CARTER
Authorized Official First Name:
LUCRETIA
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
803-396-1090

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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